State of Michigan Employee Benefits Summary For Judicial … · 2012-09-28 · Dental Care Options...

FiscalYear2012‐2013

StateofMichiganStateofMichiganStateofMichiganEmployeeBenefitsSummaryEmployeeBenefitsSummaryEmployeeBenefitsSummaryForJudicialBranchEmployeesForJudicialBranchEmployeesForJudicialBranchEmployees

AsaStateofMichiganJudicialBranch(unclassified)employee*,youareentitledto

acomprehensivebenefitspackage,includinghealth,dental,vision,lifeinsurance,

long‐termdisability,flexiblespendingaccounts,andmore.

*Non‐careeremployeesarenoteligibleforthesebenefitsbutmaybeeligibleforretirementbenefits.

StateofMichiganCivilServiceCommission

EmployeeBenefitsDivision

www.michigan.gov/employeebenefits

I m p o r t a n t N o t i c e

ThisbookletisasummaryofbenefitsprovidedtoStateofMichiganemployees1andisnotanagreementbetweenanyemployeeandtheStateofMichigan.Morecompletedetailsonbenefitsarefoundintheofficial

documents,suchastheCivilServiceRulesandRegulations,collectivebargainingagreements,departmentalworkrules,andcontractswithvariousbenefitproviders.Ifthisbookletandanofficialdocumentdiffer,the

officialdocumentgoverns.

TheNewStateHealthPlan(NSHP)PPOandNewHMO(NHMO)PlanDesignforemployeeshiredorrehired2onorafterApril1,2010,appliestojudicialemployeesNSHPPPOPremium:TheStatewillpay80%ofthetotalpremiumwithenrolledemployeespaying20%.NHMOPremium:TheStatewillpayupto85%oftheNHMOtotalPremium,cappedatthedollaramountwhichtheStatepaysforthesamecoverageundertheNSHPPPO,withenrolledemployeespayingtheremainder.1Non‐careeremployeesarenoteligibleforthesebenefitsbutmaybeeligibleforretirementbenefits.

2EmployeesreturningfromrecallorotherwisereturningtoStateemploymentwheretherehasbeennobreakinservicewillbeeligibleforenrollmentintheplaninwhichtheywerepreviouslyenrolled.Forexample,anemployeecoveredbytheStateHealthPlanPPO(SHP)whoisplacedonlayoffandthenrecalledmayenrollintheSHPuponrecall;anemployeecoveredbytheNewStateHealthPlanPPO(NSHP)whoisplacedonlayoffandthenrecalledmayenrollintheNSHPuponrecall.However,aformeremployeewithabreakinservicewhoisrehiredonorafterApril1,2010,iseligibleonlyfortheNSHPortheNHMO.ArehireissimplyaHRMNtransactioncodeusedtopreventanemployeefromhavingduplicateHRMNIDnumbers.ThistypeofhirecodeisusedwhenanapplicantishiredwhohadpreviouslybeenissuedaHRMNID.Allhireshavingtherehiretransactioncodehadabreakinservice.

Welcome!Welcome!IfyouwouldliketoparticipateintheStateofMichigan’shealth,vision,dental,

employee/dependentlife,long‐termdisability(LTD)andflexiblespending

accountbenefits,youmustenrollwithin31daysofyourhiredate.

Coveragewillbeeffectiveonthefirstdayofthebi‐weeklypayrollperiodfollowingEITHERyour

firstdayofemploymentORthedatewhentheenrollmentprocessiscompleted,whicheverislater.

Ifyouelectnottoenrollforbenefitswithinthefirst31daysofhire,yournextopportunitytoenroll

willbeduringtheannualopenenrollmentperiod,whichusuallytakesplaceinthemonthofAugust.

ThroughoutthisbenefitssummaryyouwillbeinstructedtocontacttheMIHRServiceCenterto

enrollinyourbenefitsselections.PleasenotethatLegislative,andJudicialemployeesshould

contacttheiragencyHROfficetocompleteenrollment.

New Hi re Bene f i t s Check l i s t

Thechecklistbelowwillassistyouwiththebenefitenrollmentprocess.

Reviewthisbookletforbasicinformation.

Gotowww.michigan.gov/employeebenefitstoreviewbenefitoptions.Clickthe“NewEmployee”linkfromtheleftmenu.

Determineinsurancesforwhichyouwouldliketoenroll.

ContactJudicialHumanResources(517)373‐1147toenrollinyourinsurances.Hoursare8:00a.m.to5:00p.m.MondaythroughFriday,exceptstateholidays.

MailorfaxdependenteligibilitydocumentationtoJudicialHumanResources,ifapplicable(SeeEligibilityDocumentation)

Who can enro l l ? Youmaychoosetoenrollyourspouseand/oreligibledependentsinyourhealth,dental,vision,and

lifeinsuranceplansatthetimeyouenrollasanewemployee,duringanyannualopenenrollment

period,orastheresultofalifeevent.Anytimeaspouseordependentisaddedtoyourinsurance,

youmustsubmitdependenteligibilitydocumentation(seePages17‐19)within31daysoftheevent.

Formoreinformation,visittheEmployeeBenefitsDivisionwebsiteatwww.michigan.gov/employeebenefits.

Dua l E l i g i b i l i t y IfyouandyourspouseordependentarecurrentlyworkingfortheStateofMichiganandareboth

coveredbyStateHealthPlans(retireeoractive,includingState‐sponsoredHMOoptions),youmay:

Maintainseparatecoveragethroughyourindividualplans,OR

Enrollinoneplanwithoneofyouasadependent.

Ifyouchoosetomaintainseparatecoverage,yourchildorchildrencanonlybelistedononeplan,notboth.Thisappliesevenifyouaredivorced.

I n su rance Cards Identificationcardswillbeissueddirectlyfromindividualcarriers,whenapplicable.

Genera l Bene f i t s I n f o rmat i on

Specia l Enrol lment Rights

Ifyouaredecliningenrollmentforyourselforyourdependents

(includingyourspouse)becauseofotherhealthinsuranceorgrouphealthplancoverage,youmaybeabletoenrollyourselfandyourde‐

pendentsinthisplanifyouoryourdependentsloseeligibilityforthat

othercoverage(oriftheemployerstopscontributingtowardsyouroryourdependents'othercoverage).However,youmustrequestenroll‐

mentwithin31daysafteryouroryourdependents'othercoverage

ends(oraftertheemployerstopscontributingtowardtheothercover‐age).

Specialenrollmentisalsoavailableto(1)thosewhobecomeeligibleforpremiumassistanceunderMedicaidorCHIP(Children’sHealthInsur‐

anceProgram)and(2)thosewholosecoverageunderMedicaidor

CHIPbecausetheyarenolongereligible(notbecauseofnonpayment).Thedeadlineforthesetwoenrollmentsis60daysaftereligibilityortermination.

Torequestspecialenrollmentorobtainmoreinformation,contacttheMIHRServiceCenterat(877)766‐6447or(517)335‐0529.Theyareopenfrom7amuntil6pm,MondaythroughFriday,exceptstateholidays.

General Benefi ts Information Li fe Event Changes Amarriage,birth,adoption,divorce,etc.,canbeenteredeitherinyour

MIHRSelf‐ServiceaccountorbycallingJudicialHumanResourcesat(517)373‐1147forassistance.Whenchildrenbecomeineligible,you

mustcontactJudicialHumanResourcestostopinsurancecoverage.

Changesmustbeprocessedwithin31daysofthelifeeventandmustbesubstantiatedwithappropriatedocumentation(seeEligibility

Documentation)

Benef ic iary Changes BeneficiarydesignationforfinalcompensationandlifeinsurancecanbecompletedonlineinyourJudicial

Self‐Serviceaccountatwww.courts.mi.gov/selfserv.

The401(k)DefinedContributionand457Plans(ING),andAccidentalDutyDeathcarriers

requireanoriginalsignaturetoaddorchangebeneficiaries.Theseformscanbeprinted

fromyourMIHRSelf‐Serviceaccount.Thebeneficiaryformsforthe401(k)DefinedContributionand457Plansshouldbemailedtotheaddressontheform.TheAccidental

DutyDeathformshouldbesenttoyourHROffice.

Flex ible Spending Accounts YoumaychoosetoenrollintheDependentCareand/ortheHealthCareSpendingAccounts.

Newhireshave31daysfromtheirstartdatetoenrollforcurrentyearflexiblespending

accounts.Allemployeeshavetheopportunitytoenrollfortheupcomingyear’splanduring

themonthofNovember.Michigan’sFlexibleSpendingAccountsletyoupayfordependentcareandout‐of‐pocketmedicalexpenseswithpre‐taxdollars,makingtheseexpensesmore

affordable.TheFlexibleSpendingAccountsareconvenientandeasytouse.Withalittleup‐

Other Benef i t Programs QualifiedParking

Employeeswhoparkinnon‐statefacilitiesmayauthorizebi‐weeklypayrolldeductiononapre‐taxbasisintoaQualifiedParkingSpendingAccount.Fromtheaccount,employeescanrequestreimbursementtocover

theirparkingexpenses.

AccidentalDeath&Dismemberment

MutualofOmahaistheadministratorforthisinsurance.ThisisaGroupAccidentalDeath&DismembermentcoverageofferedthroughMutualofOmahaInsuranceCompanyandmadeavailabletoStateofMichigan

employees.Premiumsarefullypaidbytheemployee.Thereareseveralothervoluntarybenefitsforwhich

youmayenroll(typicallyduringearlyspring),includingsupplementallifeinsurance,accidentinsurance,autoandhomeinsurance,andalegalplanwhichprovidesaccesstoanetworkofattorneysoverthephoneorin

personformanycommonpersonallegalissues.GototheStateEmployeeBenefitsWebsiteformore

information.http://www.mi.gov/mdcs/0,4614,7‐147‐22854_38928‐‐‐,00.html

General Benefi ts Information ThefollowingisabriefdescriptionofthevariousinsurancebenefitsofferedtoStateofMichiganemployees.CompletedetailsforeachplanareavailableontheCivilServiceCommissionwebsiteatwww.michigan.gov/

employeebenefits.

Health Care Options Youmayelectoneofthefollowinghealthinsuranceplans:

StateHealthPlan‐PreferredProviderOrganization(PPO)

TheStateHealthPlanPPOisadministeredbyBlueCrossBlueShieldofMichigan(BCBSM).

TheStatepays80%ofthepremiumforfull‐timeemployees. Thisplanprovideshealthbenefitsusingprovidersandfacilitiesthatare“in‐network,”meaningtheprovidersandfacilitieshaveagreedtoacceptadiscountedfeefromBCBSMforservicesrendered.

Providernetworkcoversall83Michigancounties. Therearedeductiblerequirements. Youmustpayofficeandprescriptiondrugco‐pays. Anemergencyroomco‐paywillberequiredifthememberisnotadmittedtothehospital. RetailpharmacyandmailorderprescriptionmedicationsareadministeredbyBCBSM. MentalhealthandsubstanceabusetreatmentservicesareadministeredbyMagellanBehavioralHealth.

HealthMaintenanceOrganization(HMO)Plans

AnHMOisamanagedcareplanthatprovidesmedicalcarethroughitsnetworkofphysicians,pharmacies,contractedhospitals,andmedicalcaresuppliersinaparticularservicearea.

Theemployerwillpay80%ofthetotalpremiumuptotheamountpaidforthesamecoveragecodeunder

theStateHealthPlanPPO.

Therearenodeductiblerequirements.

Youmustpayofficeandprescriptiondrugco‐pays.

Youcanchooseyourown“primarycarephysician”whowillprovidedirectcareandmakereferralsfrom

withinthenetwork.

Youreligibilityforenrollmentisbasedonyourpostalcodeandbargainingunit.

AzipcodelistingforeachHMOcanbeviewedontheCivilServiceCommissionwebsiteat

www.michigan.gov/employeebenefits.Clickthe“HMOEligibility”linkfromtheleftmenu.

CatastrophicHealthPlan

Thisisahospitalization‐onlyplanintendedasanoptionforthoseemployeeswhohavecoverageelsewhere.

Thisplandoesnotcoverprescriptiondrugcharges,officevisitcharges,medicalequipment,psychiatricservices,orothermajormedicalservices.

TheStatewillcover100%ofthepremiumcostforfull‐timeemployeesandyouwillreceivea$50cash

paymentbi‐weeklyforbeingenrolledinthisplan.

Benefitsunderthisplanarepayableonlyafteryouhavecoveredthoseexpensesequaltoonemonth’sbasicsalary(yourdeductiblerequirement).Thefamilydeductible(twoormoremembers)isequalto11/2

month’sbasicsalary.

General Benefi ts Information Dental Care Options Youmayselectoneofthefollowingplans:

StateDentalPlan

TheStateDentalPlanisadministeredbyDeltaDental.

TheStatewillpay95%ofthepremiumforfull‐timeemployees.

Thisplancoverspreventiveservices(examsandcleanings)at100%ofthe“usual,customary,andreasonablecharge.”

X‐rays,oralsurgery,extractions,restoratives,periodontics,andendodonticarecoveredat90%.

Orthodonticsarecoveredat60%upto$1,500.

Sealantsforchildrenandprosthodontics(includingrepairs)arecoveredat50%.

PreventiveDentalPlan

ThePreventiveDentalPlancoversdiagnosticexams,x‐rays,andcleaningstothesameextentastheState

DentalPlanandisalsoadministeredbyDeltaDental.Nootherservicesarecovered.

TheStatewillpay100%ofthepremiumforfull‐timeemployeesandyouwillreceivea$100lumpsumcashpaymenteachyear(pro‐ratedformid‐yearenrollment).

Thisplanisintendedasanoptionifyouhavedentalcoverageelsewhere.

DentalMaintenanceOrganization(DMOMidwesternDentalPlans)

ThisisamanagedcaredentalplanthatprovidesallnecessarydentalcareandservicesatMidwestern

DentalPlans’dentalcarecenters.

TheStatewillpay100%ofthepremiumforfull‐timeemployees.

Therearenomemberco‐paysrequiredforanycovereddentalcarereceivedata

dentalcenter,exceptforanorthodonticsco‐payforadults(age19andolder).

Therearenobenefitmaximums.

YourpostalcodewilldetermineifyouareeligibletoenrollintheDMO.

Vis ion Care TheStateoffersonevisionplan

StateVisionPlan

TheStateVisionPlancoversroutinevisionexaminationsand

glaucomatestingonceevery12months,andcorrectivelensesandeyeglassframesonceevery24months,unlessyourprescription

changes.

TheStatepays100%ofthepremiumforfull‐timeemployees.

Thereisaco‐paymentforexams,lenses,andframes.

General Benefi ts Information

State Long ‐Term Disabi l i ty (LTD) Plan

TheStateLong‐TermDisability(LTD)Planisanincome

continuationplanthatisavailabletoqualifiedenrolleesduringa

periodoftotaldisabilityasdefinedbythePlan.

Newemployeescanenrollwithin31daysofhire.Otherwise,you

canenrollduringtheannualOpenEnrollmentperiod.

Benefitsareequalto2/3ofyourbasicmonthlysalary.TheStatepaysaportionofthetotal

premium.Thelengthofyourbenefitperiodandyourportionofthepremiumsarebasedonyour

sickleavebalanceandregularwages.

Therearetwobenefitplans;PlanIandII.Employeeswithlessthan183hoursofsickleavearein

PlanI.Employeesaccumulating184hoursofsickleaveareinPlanII,eveniftheirsickleavebalancedropsbelow184hours.

PlanIpaysabenefituntilyouarenolongertotallydisabledor24months,whicheveroccursfirst.PlanIIpaystotallydisabledemployeesuntilage65(age70forUAWmembers)or12months,whicheverisgreater.ThePlanIIbenefitperiodfor“mental/nervous”claimsislimitedto24monthsfromthebeginningofthetimeyouareeligibletoreceivebenefits.Thislimitationdoesnotapplytomentalhealthclaimswhereyouareunderin‐patientcareortoUAWmembers.

Long ‐Term Care Long‐TermCareprovidescoverageforexpensesthatarenotusuallycoveredbyhealthordisabilityinsurance.Thiscoveragecanhelpprotectyouandyourfamilyfromthehighcostsassociatedwithprolongednursinghome

stays,extendedhomecareservices,andotherformsofdailycare.New

employeesareabletosignupwithin90daysoftheirhiredatewithouthavingtoshowevidenceofgoodhealth.TheStatedoesnotcontribute

towardsthepremiumforthiscoverage.Premiumsarefullypaidbythe

employee.

General Benefi ts Information

Employee Li fe Insurance Options Youmayselectoneofthefollowinglifeinsuranceplans:

StateLifeInsurancePlan

TheStatewillcover100%ofthepremiumcostoftheStateLifeInsurancePlan.This

isthetraditionalgrouplifeinsuranceplanthatpaysyourdesignatedbeneficiariesa

non‐taxabledeathbenefitequaltotwotimesyourbasicannualsalaryroundedupto

thenext$1,000,uptoamaximumof$200,000.

ReducedBenefitLifeInsurancePlan

TheReducedBenefitLifeInsurancePlanpaysyourdesignatedbeneficiariesanon‐taxabledeath

benefitequalto100%ofyourbasicannualsalaryoruptoamaximumof$50,000.Youwillreceivea

bi‐weeklycashpaymentforselectingthisreducedlifeinsuranceoption.

NOTE:Bothofthelifeinsuranceoptionsaboveincludea$100,000dutydeathbenefit.

Dependent Li fe Insurance Options YouhavetheoptionofenrollingyourlegalspouseandeligiblechildreninoneoftheDependentLifeInsuranceplans.Theseplanswillcoveryourspouseandunmarriedchildrenbetweentheagesof14daysand23years.Unmarrieddependentchildrenbetweentheagesof19and23arenotrequiredtohavestudenteligibilitytobeenrolledindependentlife.TheStatedoesnotcontributetowardsthepremiumforthiscoverage.Premiumsarefullypaidbytheemployee.

Retirement Benefi ts

Def ined Contr ibut ion Ret irement Plan EmployeeshiredonorafterMarch31,1997areenrolledinthe401(k)DefinedContributionPlan.

TheStatewillcontributeanamountequalto4%ofyourgross

wagestoyour401(k)forretirement.TheStatewillalsomatchup

to3%ofyourbi‐weeklycontributions.Contributionsaresubjectto

IRSguidelines.Formoreinformationaboutthis401(k)planandto

learnaboutinvestmentoptionsgoto

https://stateofmi.ingplans.comorcall(800)748‐6128.

Personal Healthcare Fund EmployeeshiredonorafterJanuary1,2012maycontributetoapersonal,portablefundthatyoucanusetopayyourhealthcareexpensesinretirement.ThePersonalHealthcareFundincludesuptoa2percentemployermatchintoyour401(k)accountandalumpsumcredittoataxdeferredaccountwhenyouterminateemployment,assumingyoumeeteligibilityrequirements.

Matching Contr ibut ions ThePersonalHealthcareFundincludesuptoa2percentemployermatchintoyour401(k)accountifyoucontributeupto2percentofpayinadditiontothe3percentyoucontributetoqualifyforthematchyou'realreadyeligiblefor.

Torevieworchangeyourcurrentlevelofcontributions,logintoyourINGaccountatstateofmi.ingplans.comorcontactINGat(800)748‐6128.

Lump Sum Credi t ThePersonalHealthcareFundalsogivesyoualumpsumcredittoatax‐deferredaccount(which

maybeyour401(k)oryour457)ifyouhaveatleast10yearsofservicewhenyoufirstterminateemploymentfollowingDecember31,2011.Theamountofthelumpsumcreditwillbebasedonastatutoryformula,whichincludesyouryearsofserviceasofMarch31,2012,thecurrentvalueofyourretireehealthbenefits,andanannualinterestadjustmentbasedontheMedicalCareComponentoftheConsumerPriceIndex(nottoexceed4percent).Eachspring,youwillreceiveanannualstatementonthevalueofyourlumpsumamount.

Def ined Benef i t Ret irement Plan TheDefinedBenefitPensionRetirementPlanisforallemployeehiredbeforeMarch31,1997,unlessyouelectedtotransfertothestate's401(k)DefinedContributionretirementplanunderP.A.487of1996.TherearethreeplanswithintheDefinedBenefit(DB)retirementplan‐DBClassified,DB30,andDB/DCBlend

DB Class i f ied AsaDBClassifiedmember,you'llremainanactivecontributingmemberoftheDBplanuntilyouterminateemployment.

DB 30 AsaDB30member,you'llremainanactivecontributingmemberoftheDBplanuntilyoureach30yearsofservice.Atthatpoint,you'llbecomeaparticipantintheDefinedContribution(DC)planforfutureservice.YourstatusintheDBplanwillbeactivenoncontributingmember.Whenyouretire,yourretirementbenefitswillbecomprisedofyourpensionandtheassetsinyourDCplanaccounts.YouremaineligibleforretireehealthinsuranceundertheDBplan.

DB/DC Blend AsaDB/DCBlendmember,youbecameaparticipantintheDCplanforfutureservicebeginning

April1,2012.YourstatusintheDBplanisactivenoncontributingmember.Whenyouretire,yourretirementbenefitswillbecomprisedofyourpensionandtheassetsinyourDCplanaccounts.YouremaineligibleforretireehealthinsuranceundertheDBplan.

ForallDCblendplanspleaserefertoINGforplaninformationat:https://stateofmi.ingplans.comorcall(800)748‐6128.

Information You Must Read

COBRA (ConsolidatedOmnibusBudgetReconciliationAct)Severaldifferenteventsmaytriggerthelossofinsurancecoverage

foremployees(e.g.,separation,leave,layoff,reductionofhours),

spouses(e.g.,divorce,deathofemployee),ordependentchildren

(e.g.,age19orolderandnotregularlyattendingschool,reaching

age25,ormarriage).

UnderCOBRA,ifyou,aspouse,ordependentshouldloseeligibilityforstate‐sponsored

grouphealth,dental,orvisioninsurances,youmaybeeligibletocontinuethesecoverages

foraperiodoftimebypayingthefullpremiumdirectlytotheStateofMichigan.Thisfull

premiumwillincludetheamountpreviouslypaidasthe“Employee’sShare”plusthe“State’sShare”and,insomecases,anadditional2%servicefee.

YoumayalsobeeligibletocontinueyourlifeinsurancecoverageatnocostforyouoryourdependentsifyouareonaleaveofabsenceorlayofffromStateservice.

HIPAA (HealthInsurancePortability&AccountabilityAct) TheEmployeeBenefitsDivisionoftheCivilServiceCommissioncurrentlyadministersthefollowingself‐insuredgrouphealthplansforStateemployeesandretireesonbehalfoftheStateofMichigan:

StateHealthPlanPPO(BCBSM/Magellan) StateCatastrophicHealthPlan(BCBSM) StateVisionPlan(BCBSM) StateDentalPlan(DeltaDental) PreventiveDentalPlan(DeltaDental) FlexibleSpendingAccounts(ADP)

TheHealthInsurancePortability&AccountabilityAct(HIPAA)andrelatedrulesrequire

grouphealthplanstoprotecttheprivacyofhealthinformation.YourrightsunderHIPAAareoutlinedinthePrivacyNoticeavailableontheCivilServiceCommissionwebsiteat

www.michigan.gov/employeebenefits.Clickthe“HIPAA”linkfromtheleftmenu.

Enroll ing in Benefi ts

Judic ia l (MI HR) Sel f ‐Service Judicial(MIHR)Self‐Serviceisanonlineweb‐basedtooldesignedtoprovideyouwithaccesstoupdateandviewyourpersonnelinformation.AsanewStateemployee,youwillbeprovidedaccesstoJudicial(MIHR)Self‐Service.Thisonlinetoolallowsyoutoupdateyourpersonalrecordssuchasaddressandhomephone,emergencycontacts,e‐mailaddress,beneficiaries,anddirectdeposits.Duringspecialenrollmentperiods,youcancompleteyourGroupInsuranceOpenEnrollment,FlexibleSpendingAccountOpenEnrollment,and/ormakecontributionsduringtheStateEmployeesCharitableCampaign(SECC).Youcanalsogetupdatedinformationandformsforinsurancecoverage,taxwithholding,leavebalances,earningstatements,andmore.

New Employees YourJudicial(MIHR)Self‐ServiceaccountwillbecreatedonedayafteryourHROfficeentersyourhireinformationintothesystem.HumanResourcesManagementNetwork(HRMN)CentralSecuritywillcreateyourSelf‐Serviceaccountandsendthefollowingcorrespondencetoyou:AletterwillbemailedtothehomeaddressonfilenotifyingyouthatyourJudicial(MIHR)Self‐Serviceaccounthasbeencreated.Itwillcontain;yourjudicial(MIHR)Self‐Serviceusername,awalletcardwithyourusername,additionalwebaddressesandcontactinformation,picturedabove.

IfyouhaveavalidStateofMichiganemailaddress,anemailwithatemporaryPIN,instructionsonhowtoactivateyourJudicial(MIHR)Self‐Serviceaccountandhowtoreceiveyournewpasswordwillbeemailedtoyou.Ifyoudonothaveavalidemailaddress,thisinformationwillbemailedtoyourhomeaddressonfile.

Onceyou'veactivatedyouraccountandreceivedyourpassword,athankyounotificationwillbesenttoyourvalidStateofMichiganemailaddressortoyourhomeaddressonfileifyoudon'thaveavalidemailaddress.Thenotificationwillalsocontaintheaddresstotheself‐serviceloginpage.

Ifyouhavedifficultyobtainingyourfirstpasswordorwouldlike

MI HR Service Center NewJudicialemployeesshouldenrollforbenefitsbycontactingtheiragencyHROffice(517)373‐1147.

Forbenefitsandenrollmentquestionsoutsideofnormal

businesshours,theMIHRServiceCenterhasastaffofStateofMichiganHRemployeeswhoareavailabletohelp.TheMIHR

ServiceCenterisavailablefrom7:00a.m.to6:00p.m.,Monday

throughFriday,exceptstateholidays.

Documentationmustbemailed/faxedtoJudicialHuman

Resourceswithin31daysfromthedateyouenrolldependents

inyourinsurances.

SeeEligibilityDocumentationforalistofacceptabledocuments.

Contact

JudicialHR

Judicial

Resources

Eligibi l i ty Documentation Belowisalistingofdocumentsthatcanbeusedtoprovedependenteligibilityforinsurancecoverage.Thisdocumentationmustbemailed/faxedtoJudicialHumanResourceswithin31daysfromthedateyouenrolldependentsinyourinsurances.

FormscanbefoundontheEmployeeBenefitsDivisionwebsite.

A.RequiredDocumentationforDependents(Health,Dental,andVisionCoverage)SpecificCircumstance RequiredDocumentation

Spouse Copyofmarriagecertificate

Biologicalchild Copyofanofficialbirthcertificate(nothospitalbirthcertificate)

Legallyadoptedorpendingadoption Copyofadoptionpapersorswornstatementwiththedateofplacement

Legalguardianship Copyofguardianshippapers

Dependentchildhasababy Copyofanofficialbirthcertificate(nothospitalbirthcertificate)

Fosterchild Courtdocumentplacingthechildintheemployee’shomeforfostercare

Stepchild

Copyofanofficialbirthcertificate(nothospitalbirthcertificate)andacopyofthemarriagecertificate(ifnotpreviouslyprovidedtoobtainspousecoverage).Ifdentalandvisioncoverageissought,acopyofthefirstandlastpagesofthemostcurrentdivorcedecreeoftheemployee’sspousestampedbythecourtandanylanguageverifyingphysicalcustodyisalsorequired.

Dependentstudentchildaged19to25Inadditiontorequireddocumentationestablishingthechildrelationship,acompletedVerificationofEligibility (CS‐1830) form and a copy of school registration or other records proving schoolattendance.

Incapacitatedchild RefertotheEligibilityGuidelinesifnotpreviouslyapproved

B.RequiredDocumentationforAdultChildrentoAge26(HealthCoverageOnly)

SpecificCircumstance RequiredDocumentation

Biologicalchild Copyofanofficialbirthcertificate(nothospitalbirthcertificate)

StepchildCopyofanofficialbirthcertificate(nothospitalbirthcertificate)andacopyofamarriagecertificate(ifnotpreviouslyprovidedtoobtainspousecoverage)

Legallyadoptedorpendingadoption Copyofadoptionpapersorswornstatementwiththedateofplacement

Legalguardianship Copyofguardianshippapers

Inadditiontotherequireddocumentationnotedabove,asignedVerificationofEligibility(CS‐1830)formattestingthatthechilddoesnothaveaccesstootheremployer‐providedhealthinsuranceisrequired.

C.RequiredDocumentationforDependentLifeInsurance

Dependentlifeinsurancecoverageonly Copyofofficialbirthcertificate,adoptionpapers,courtdocuments,etc.

D.RequiredDocumentationforOtherCircumstances

Removingex‐spouse,dependent/stepchild(ren)duetoadivorce

Copyofthefirstandlastpageofthedivorcedecreestampedbythecourt

Removingdependentcoverageduetodeath Copyofdeathcertificate

Lossorgainofcoverage Documentdetailingloss/gainofcoveragefromemployerorinsuranceprovider.

Ifyouhaveanyquestionsondocumentationrequirements,contactJudicialHumanResources(517)373‐1147

STATEHEALTHPLANPPOBCBSMStateofMichiganServiceCenter(800)843‐4876www.bcbsm.com/som

STATECATASTROPHICHEALTHPLANBCBSMStateofMichiganServiceCenter(800)843‐4876www.bcbsm.com/som

MANAGEDPHARMACY/MAILSERVICEPRESCRIPTIONDRUGPROGRAMBCBSMStateofMichiganServiceCenter(800)843‐4876www.bcbsm.com/som

STATEVISIONPLANBCBSMStateofMichiganServiceCenter(800)843‐4876www.bcbsm.com/som

MENTALHEALTH/SUBSTANCEABUSESERVICESMagellanBehavioralofMichigan(866)503‐3158www.magellanassist.com

STATEDENTALPLANandPREVENTIVEDENTALPLANDeltaDentalPlanofMichigan(800)524‐0150www.deltadentalmi.com

STATELONGTERMDISABILITY(LTD)PLANCitizensManagement,Inc.(800)324‐9901

DENTALMAINTENANCEORGANIZATION(DMO)MidwesternDentalPlans,Inc.(800)544‐6374www.midwesterndental.comSt

ate‐SponsoredGroupInsurancePlan

ProviderInformation

BlueCareNetwork,EastBlueCareNetwork,GreatLakesWestBlueCareNetwork,Mid‐MichiganBlueCareNetwork,Southeast(800)662‐6667www.mibcn.comTheOpenEnrollmenthotlineis(800)470‐9633.(AvailableonlyduringOpenEnrollmentperiod.)

McLarenHealthPlan(888)327‐0671www.mclarenhealthplan.orgPhysiciansHealthPlan(Lansing)(517)364‐8500or(800)832‐9186www.phpmm.orgPriorityHealth,WestPriorityHealth,EastPriorityHealth,South(800)446‐5674www.priority‐health.com

GrandValleyHealthPlan(800)335‐1977(616)949‐2410www.gvhp.com

HealthAlliancePlan(800)422‐4641www.hap.org

HealthPlusofMichigan(Flint)(800)332‐9161(Saginaw)(800)942‐8816www.healthplus.com

TotalHealthCare(313)871‐2000or(800)826‐2862www.totalhealthcareonline.com

HealthMaintenanceOrganizations

Provider Information

BenefitComparisonChart&BenefitComparisonChart&BenefitComparisonChart&BiBiBi‐‐‐weeklyInsuranceRatesweeklyInsuranceRatesweeklyInsuranceRates

ForTheBenefitYearForTheBenefitYearForTheBenefitYear

October2012October2012October2012———September2013September2013September2013

Comparison of Health Care Options Hired Prior to April 1, 2010

Disc la imer Thisisintendedasaneasy‐to‐readsummary.Itisnotacontract.Additionallimitationsandexclusionsmayapplytocoveredservices.PaymentamountsarebasedontheBlueCrossBlueShieldofMichiganapprovedamount,lessanyapplicabledeductibleand/orco‐payamountsrequiredbytheStateHealthPlanPPO.ThiscoverageisprovidedpursuanttoacontractenteredintointheStateofMichiganandshallbeconstruedunderthejurisdictionandaccordingtothelawsoftheStateofMichigan.MSPTAmembersshouldreferencetheBenefitComparisonChartforMembersoftheStatePoliceEnlistedUnit.

Prevent ive Services

$1,500 per year per person (State Health Plan PPO only)

StateHealthPlanPPO HMOBenefits

In‐network Out‐of‐network

HealthmaintenanceexamCovered100%1peryear

NotCovered

AnnualgynecologicalexamCovered100%

1percalendaryear NotCovered

Papsmearscreening–laboratoryservicesonly1

Covered100%1peryear NotCovered

Well‐babyandchildcare Covered100% NotCovered

Immunizations2,annualflushot&HepatitisCscreeningforthoseatrisk

Covered100% NotCovered

Fecaloccultbloodscreening1 Covered100% NotCovered

Flexiblesigmoidoscopy1 Covered100% NotCovered

Colonoscopy1&2 Covered100% NotCovered

Prostatespecificantigenscreening1

Covered100%oneperyear NotCovered

Covered100%after$10officevisitco‐paymentCovered100%after$10officevisitco‐payment

Covered100%

Covered100%after$10officevisitco‐payment

Covered100%

Covered

1 American Cancer Society guidelines apply 2 Childhood immunizations and colonoscopy exams are excluded from the maximum limit

Mammography1

Annualstandardfilmmammographyscreening(coversdigitalmammographyuptothestandardfilmrate)

Covered100%Notsubjecttopreventativemaximum

Covered90%afterdeductibleNotsubjecttopreventativemaximum

Covered100%

Physic ian Off ice Services

Officevisits,consultationsandurgentcarevisits

Covered$15co‐pay,

deductiblenotapplicable

Covered90%afterdeductible

$10co‐pay

OutpatientandhomevisitsCovered100%after

deductibleCovered90%after

deductible $10co‐pay

Emergency Medical Care2

Hospitalemergencyroomformedicalemergencyoraccidentalinjury

Covered100%aftera$50co‐payifnotadmitted

$50co‐payifnotadmitted

Ambulanceservices–medicallynecessary

Covered100%afterdeductible Covered100%

2Emergencyroomandphysicianchargesarecovered100%undertheCatastrophicHealthPlan.Ambulanceiscovered$25maximum.

Diagnost ic Services

LaboratoryandpathologytestsCovered100%after

deductibleCovered100%

Diagnostictestsandx‐raysCovered100%after

RadiationtherapyCovered100%after

Materni ty Services Includescarebyacertifiednursemidwife(StateHealthPlanPPOonly)

Prenatalandpostnatalcare

OfficeVisit$10co‐pay

Deliveryandnurserycare3Covered100%afterdeductible

Covered100%

Hospita l Care

Semi‐privateroom,inpatientphys ic ian care,generalnursingcare,hospitalservicesandsupplies

Covered100%afterdeductible,unlimited

Covered90%afterdeductible,

unlimiteddays

Covered100%

Unlimiteddays

InpatientconsultationsCovered100%after

deductible

Chemotherapy

Covered100%

Alternat ives to Hospita l Care

Skillednursingcareupto120daysperconfinement(730daysforUAW)

Covered100%

upto730days

HospicecareCovered100%

LimitedtothelifetimedollarmaximumthatisadjustedannuallybytheState

Covered100%

HomehealthcareCovered100%

afterdeductible,unlimitedvisitsCheckwithyour

Surgica l Services

Surgery—includesrelatedsurgicalservices.4

Covered100%after

deductible

Covered100%

VoluntarysterilizationCheckwithyour

4 Inpatienthospitalservicesare100%coveredafterdeductibleundertheCatastrophicHealthPlan.

Bonemarrow—specificcriteriaapply

Covered100%afterdeductibleindesignatedfacilities

Covered100%indesignatedfacilities

Kidney,cornea,andskinCovered100%

subjecttomedicalcriteria

Organ and Tissue Transplants

Other Services

AllergytestingandinjectionsCovered100%after

deductible

Officevisits:$10co‐payInjections:

Covered100%

Acupuncture

Covered90%afterdeductibleifperformedbyor

underthesupervisionofaM.D.

orD.O.

CheckwithyourHMO

Rabiestreatmentafterinitialemergencyroomvisit

Officevisits:$10co‐payInjections:

Covered100%

Chiropractic/spinalmanipulation

Covered100%after$15co‐pay

Upto24visitspercalendaryear

CheckwithyourHMO

Durablemedicalequipment

Covered100%Covered80%after

deductibleCovered

Prostheticandorthoticappliances

orD.O.

Human Organ Transplants

State Health Plan PPO HMO Benefits

In-network Out-of-network

Liver, heart, lung, pancreas, and other specified organ transplants

Covered 100% in designated

facilities

Covered 100% In designated facilities only. Up to $1 million lifetime maximum for each organ transplant

Comparison of Health Care Options Hired Prior to Apri l 1, 2010

Other Services cont inued . . .

Privatedutynursing Covered90%afterdeductible Covered

Wig,wigstand,adhesives

Uponmeetingmedicalconditions,eligibleforalifetimemaximumreimbursementof

$300.(Additionalwigscoveredforchildrenduetogrowth).

CheckwithyourHMO

Lasereyesurgery(MSEAemployeesonly)

$755lifetimelimitCheckwithyourHMO

Hearingcare$15co‐payforofficevisit

CheckwithyourHMO

Notcovered6

Uponmeetingmedicalconditions,eligibleforalifetimemaximumreim‐bursementof$300.(Additionalwigscov‐eredforchildrendueto

growth).

$755lifetimelimit

Mental Health/Substance Abuse

MentalHealthBenefits‐Inpatient

Covered100%upto365

daysperyear7

Covered50%upto365daysper

MentalHealthBenefits‐Outpatient

Asnecessary90%ofnetworkrates10%

co‐pay

Asnecessary50%ofnetwork

Alcohol&ChemicalDependencyBenefits‐Inpatient

Covered100%8HalfwayHouse100%

Alcohol&ChemicalDependencyBenefits‐Outpatient

$3,500percalendaryear

90%ofnetworkrates10%co‐pay9

50%ofnetworkrates

7Inpatientdaysmaybeutilizedforpartialdayhospitalization(PHP)at2:1ratio.OneinpatientdayequalstwoPHPdays.

8Uptotwo28‐dayadmissionsperyear.Theremustbeatleast60daysbetweenadmissions.Inpatientdaysmaybeutilizedforintensiveoutpatienttreatment(IOP)at2:1ratio.OneinpatientdayequalstwoIOPdays.

9$3,500percalendaryearlimitationpertainstoservicesforchemicaldependencyonly.

CheckwithyourHMO

6Notallareashaveanetworkofhearingproviders.Ifthereisnonetworkinyourarea,yourprovidermayparticipateonaperclaimbasis.Ifyourpro‐viderdoesnotwishtoparticipate,youmaypayforservicesandsubmitaclaim.Youwillbereimburseduptotheallowedamountforcoveredservices.

PrescriptionmedicationsfortheStateHealthPlanPPOarecoveredundertheParticipatingPharmacyIDCardPlanadministeredbyBCBSM.

Prescriptionsfilledataparticipatingpharmacymayonlybeapprovedforuptoa34‐daysupply.Employeescanstillreceivea90‐daysupplybymailorder.

Tochecktheco‐payfordrugsyoumaybetaking,visitBCBSMwebsiteat

http://www.bcbsm.com/somorcontactBCBSMat(800)843‐4876.ThePreferred/Non‐preferred

listofdrugsisupdatedperiodicallyasnewdrugsareadded.

ForinformationaboutHMOprescriptiondrugcoverage,checkwiththeHMOprovider.

Prescr ipt ion Drugs

EmployeeGroup Generic BrandNamePreferred

BrandNameNon‐Preferred

JudicialEmployees

Retail$10

MailOrder$20

Retail$20

MailOrder$40

Retail$40

MailOrder$80

10Theprescriptiondrugprogramwillpromotetheuseofgenericdrugs.Prescriptionmedicationsonthemaintenancedruglist(MDL)usedonalongtermbasiswillbeavailableonlythroughmailorderhomedeliveryperthetermsofthecontract.

State Health Plan PPO HMO Benefits

In-network Out-of-network Outpatient physical, speech and occupational therapy – facility and clinic services

Covered 100% after deductible

Office visit: $10 co-pay

Outpatient physical therapy – physician’s office

Office visit: $10 co-pay

Outpat ient Physica l , Speech , and Occupat ional Therapy Combined maximum of 90 visits per calendar year.

Deductible$300permember$600perfamily

$600permember$1,200perfamily

Fixeddollarco‐pays

$15forofficevisits,officeconsultations,urgentcarevisits,osteopathicmanipulations,

chiropracticmanipulationsandmedicalhearingexams.

$50foremergencyroomvisits,ifnotadmitted

Notapplicable,butdeductibleandco‐

payapply

$10forofficevisits$50for

emergencyroomvisits,ifnotadmitted

Percentco‐pays10%forprivatedutynursing,chiropracticmanipulation(forMCOmembers)andacupuncture

10%formostservices

Annualout‐of‐pocketdollarmaximums11

$1,000permember$2,000perfamily

$2,000permember$4,000perfamily None

Deduct ib le , Co ‐Pays , and Out ‐of ‐Pocket Dol lar Maximums

11 Theout‐of‐pocketlimitdoesnotapplytodeductibles,fixeddollarco‐payments,orprivatedutynursingco‐payments.

Comparison of Dental Care Options

Thisbenefitsummaryisabriefexplanationonly.Allplanprovisions(includingexclusionsandlimitations)aresubjecttothespecifictermsoftheStateandPreventiveDentalPlansandtheGroupDentalServicesAgreement(MidwesternDentalPlans,Inc.).

Dental Care Options

*IfyouhavetheStateDentalPlanasyourdentalcoverage,thelevelofcoverageisdeterminedbythepro‐videryouchoose.ToverifythataDentistisaParticipatingDentist,youcanuseDeltaDental’sonlineDentistDirectoryatwww.deltadentalmi.comorcall(800)524‐0150.

CoveredServices

StateDentalPlan(Delta) DMOPlan

(Midwestern)Premier/Non‐Part*

DiagnosticExamsandConsultations(2peryear)

100% 100% 100% 100%

PreventiveServicesTeethcleaning(3peryear)

Topicalfluoride(underage19)

Spacemaintainers(underage14)

Sealants(underage14)

NotCovered

Radiographs 90% 100% 100% NotCovered

BrushBiopsy 100% 100% N/A 100%

OralSurgery 90% 90% 100% 100%

Extractions 90% 100% 100% NotCovered

MinorRestoratives 90% 100% 100% NotCovered

MajorRestoratives 90% 90% 100% NotCovered

Endodontics 90% 100% 100% NotCovered

Periodontics 90% 100% 100% NotCovered

Prosthodontics 50% 70% 100% NotCovered

ProsthodonticsRepair 50% 100% 100% NotCovered

OrthodonticsUptoage19

19andover

$1,250co‐pay

NotCovered

BenefitMaximumsAnnual(Oct.–Sept.)LifetimeOrthodontics

$1,500$1,500

NoneNone

NoneN/A

PreventiveDentalPlan(Delta)

Comparison of Health Care Options - Hired On or After April 1, 2010

NewStateHealthPlanPPO NHMOBenefits

HealthmaintenanceexamCovered100%1peryear

NotCovered

AnnualgynecologicalexamCovered100%

1percalendaryear NotCovered

Papsmearscreening–laboratoryservicesonly1

Covered100%1peryear

NotCovered

Well‐babyandchildcare Covered100% NotCovered

Immunizations2,annualflushot&HepatitisCscreeningforthoseatrisk

Covered100% NotCovered

Fecaloccultbloodscreening1 Covered100% NotCovered

Flexiblesigmoidoscopy1 Covered100% NotCovered

Colonoscopy1&2 Covered100% NotCovered

Prostatespecificantigenscreening1

Covered100%oneperyear NotCovered

Covered100%after$20officevisitco‐paymentCovered100%after$20officevisitco‐payment

Covered100%

Covered100%after$20officevisitco‐payment

Covered100%

CheckwithHMO

Prevent ive Services

Disc la imer Thisisintendedasaneasy‐to‐readsummaryforemployeeshiredorrehiredonorafterApril,1,2010.Itisnotacontract.Additionallimitationsandexclusionsmayapplytocoveredservices.Paymentamountsarebasedonthe Blue Cross Blue Shield of Michigan approved amount, less any applicable deductible and /or co‐payamountsrequiredbytheNewStateHealthPlanPPO.Thiscoverageisprovidedpursuanttoacontractenteredinto in theStateofMichiganand shallbeconstruedunder the jurisdictionandaccording to the lawsof theStateofMichigan.

1AmericanCancerSocietyguidelinesapply2Childhoodimmunizationsandcolonoscopyexamsareexcludedfromthemaximumlimit

Mammography1

Annualstandardfilmmammographyscreening(coversdigitalmammographyuptothestandardfilmrate)

Covered100%Notsubjecttopreventativemaximum

Covered80%afterdeductibleNotsubjecttopreventativemaximum

Covered100%

1 AmericanCancerSocietyguidelinesapply

Physic ian Off ice Services

Officevisits,consultationsandurgentcarevisits

$20co‐pay,deductiblenotapplicable

OutpatientandhomevisitsCovered90%after

deductible

$20co‐pay

Hospitalemergencyroomformedicalemergencyoraccidentalinjury

$200co‐payifnotadmitted $200co‐payifnotadmitted

Ambulanceservices–medicallynecessary

Covered90%afterdeductible Covered100%

2Emergencyroomandphysicianchargesarecovered100%undertheCatastrophicHealthPlan.Ambulanceiscovered$25maximum.

Emergency Medical Care2

New State Health Plan PPO NHMO Benefits

Skillednursingcareupto120daysperconfinement

Covered100%

HospicecareCovered100%

LimitedtothelifetimedollarmaximumthatisadjustedannuallybytheState

Covered100%

HomehealthcareCovered90%

afterdeductible,unlimitedvisitsCheckwithyour

Alternat ives to Hospita l Care

Surgery—includesrelatedsurgicalservices.4

Covered90%after

deductible

Covered100%

VoluntarysterilizationCheckwithyour

Surgica l Services

4Inpatienthospitalservicesare100%coveredafterdeductibleundertheCatastrophicHealthPlan.

Liver,heart,lung,pancreas,andotherspecifiedorgantransplants

Covered90%Indesignatedfacilitiesonly.Upto$1millionlifetimemaximumforeachorgantransplant

Human Organ Transplants

Bonemarrow—specificcriteriaapply

Kidney,cornea,andskinCovered100%

subjecttomedicalcriteria

Covered80%after

deductible

Organ and Tissue Transplants

Other Services NewStateHealthPlanPPO NHMOBenefits

AllergytestingandinjectionsCovered90%after

deductibleCheckwithyour

Acupuncture

orD.O.

CheckwithyourHMO

Rabiestreatmentafterinitialemergencyroomvisit

CheckwithyourHMO

Chiropractic/spinalmanipulation$20co‐pay

CheckwithyourHMO

Durablemedicalequipment‐SupportProgram

Covered100%Covered80%ofapprovedcharges

CheckwithyourHMO

Prostheticandorthoticappliances‐SupportProgram

orD.O.

Covered100%Covered80%ofapprovedcharges

CheckwithyourHMO

Other Services cont inued . . .

NewStateHealthPlanPPO NHMOBene‐fits

Privatedutynursing Covered80%afterdeductible Covered

Wig,wigstand,adhesives

Uponmeetingmedicalconditions,eligibleforalifetimemaximumre‐imbursementof$300.(Additionalwigscov‐eredforchildrendueto

growth).

CheckwithyourHMO

HearingCareExam$20co‐payforofficevisit

Covered80%afterde‐ductible

CheckwithyourHMO

Uponmeetingmedicalconditions,eligibleforalifetimemaximumreimbursementof$300.(Additional

wigscoveredforchil‐drenduetogrowth).

Lasereyesurgery(MSEAemployeesonly)

$755lifetimelimit $755lifetimelimit CheckwithyourHMO

Mental Health/Substance Abuse

MentalHealthBenefits‐Inpatient

Covered100%upto365daysperyear6

Covered50%upto365daysper

MentalHealthBenefits‐Outpatient

Asnecessary90%ofnetworkrates10%

co‐pay

Asnecessary50%ofnetwork

Alcohol&ChemicalDependencyBenefits‐Inpatient

Alcohol&ChemicalDependencyBenefits‐Outpatient

90%ofnetworkrates10%co‐pay8

50%ofnetworkrates

6Inpatientdaysmaybeutilizedforpartialdayhospitalization(PHP)at2:1ratio.OneinpatientdayequalstwoPHPdays.

7Uptotwo28‐dayadmissionsperyear.Theremustbeatleast60daysbetweenadmissions.Inpatientdaysmaybeutilizedforintensiveoutpatienttreatment(IOP)at2:1ratio.OneinpatientdayequalstwoIOPdays.

8$3,500percalendaryearlimitationpertainstoservicesforchemicaldependencyonly.

CheckwithyourHMO

PrescriptionmedicationsfortheNewStateHealthPlanPPOarecoveredundertheParticipatingPharmacyIDCardPlanadministeredbyBCBSM.

Prescriptionsfilledataparticipatingpharmacymayonlybeapprovedforuptoa34‐daysupply.Employeescanstillreceivea90‐daysupplybymailorder.

Tochecktheco‐payfordrugsyoumaybetaking,visitBCBSMwebsiteat

http://www.bcbsm.com/somorcontactBCBSMat(800)843‐4876.ThePreferred/Non‐preferred

listofdrugsisupdatedperiodicallyasnewdrugsareadded.

ThechartbelowshowstheNSHPandNHMOprescriptiondrugmemberco‐pays:

ForinformationaboutHMOprescriptiondrugcoverage,checkwiththeHMOprovider.

Prescr ipt ion Drugs

Generic

BrandNamePreferred

BrandNameNon‐Preferred

Retail$10

MailOrder$20

Retail$30

MailOrder$60

Retail$60

MailOrder$120

In‐network Out‐of‐network Outpatientphysical,speechandoccupationaltherapy–facilityandclinicservices

Covered90%afterdeductible CheckwithHMO

Outpatientphysicaltherapy–physician’soffice

Covered80%afterdeductible CheckwithHMO

Outpat ient Physica l , Speech , and Occupat ional Therapy

Deductible $400permember$800perfamily

$800permember$1,600perfamily

Fixeddollarco‐pays

$20forofficevisits,officeconsultations,urgentcarevisits,osteopathicmanipulations,

chiropracticmanipulationsandmedicalhearingexams.

Notapplicable

$20forofficevisits

Coinsurance10%formostservicesand20%forprivatedutynursingand

acupuncture

20%formostservices.MHSAat

50%None

Annualout‐of‐pocketdollarmaximums9

$1,500permember$3,000perfamily

$3,000permember$6,000perfamily None

Deduct ib le , Co ‐Pays , and Out ‐of ‐Pocket Dol lar Maximums

9Theout‐of‐pocketlimitdoesnotapplytodeductibles,fixeddollarco‐payments,orprivatedutynursingco‐payments.

Rates: Judicial Branch, AFSCME, MCO, & MSEA, prior to Apri l 1, 2010

FY2012‐2013GROUPINSURANCEPREMIUMRATESFOREMPLOYEESHIREDPRIORTOAPRIL1,2010,EFFECTIVEOCTOBER14,2012

ForJudicialBranchandBargainingUnits:MSEA(A02,A31),MCO(C12),AFSCME(U11)

Note:WhenchoosingaHMOorDMOplan,besuretoreviewavailabilityinyourarea.TheZipCodeListisavailableatwww.michigan.gov/employeebenefits.ChooseInsuranceOpenEnrollment.

BIWEEKLY1 BIWEEKLY Part‐timeemployees

Option2 Employee State Employee State

PLANNAME (a) (b) (c) (d) (e)

HEALTHPLANS

StateHealthPlanPPO 1 $ 54.93 $ 219.73 $ 137.33 $ 137.33

2 $ 109.87 $ 439.46 $ 274.66 $ 274.66

3 $ 96.68 $ 386.73 $ 241.71 $ 241.71

4 $ 151.62 $ 606.46 $ 379.04 $ 379.04

EmployeeorSpousewithMedicare(Statepays100%)

CatastrophicHealthPlan 1 $ ‐ $ 15.81 $ 7.91 $ 7.91

EmployeesintheCatastrophicHealthPlanwillreceivea 2 $ ‐ $ 31.62 $ 15.81 $ 15.81

$50rebatewitheachpaycheckbeginningOctober25,2012. 3 $ ‐ $ 31.62 $ 15.81 $ 15.81

4 $ ‐ $ 31.62 $ 15.81 $ 15.81

DeclineHealthInsuranceCoverage3 (n/a)

BlueCareNetwork,Mid‐Michigan 1 $ 52.03 $ 219.73 $ 135.88 $ 135.88

2 $ 104.07 $ 439.46 $ 271.77 $ 271.77

3 $ 91.58 $ 386.73 $ 239.16 $ 239.16

4 $ 143.62 $ 606.46 $ 375.04 $ 375.04

BlueCareNetwork,EastMichigan 1 $ 54.28 $ 219.73 $ 137.01 $ 137.01

2 $ 108.55 $ 439.46 $ 274.01 $ 274.01

3 $ 95.53 $ 386.73 $ 241.13 $ 241.13

4 $ 149.81 $ 606.46 $ 378.13 $ 378.13

BlueCareNetwork,GreatLakesWest 1 $ 54.27 $ 219.73 $ 137.00 $ 137.00

2 $ 108.54 $ 439.46 $ 274.00 $ 274.00

3 $ 95.52 $ 386.73 $ 241.12 $ 241.12

4 $ 149.79 $ 606.46 $ 378.12 $ 378.12

BlueCareNetwork,SoutheastMichigan 1 $ 50.76 $ 219.73 $ 135.25 $ 135.25

2 $ 101.53 $ 439.46 $ 270.50 $ 270.50

3 $ 89.34 $ 386.73 $ 238.04 $ 238.04

4 $ 140.10 $ 606.46 $ 373.28 $ 373.28

GrandValleyHealthPlan 1 $ 75.88 $ 219.73 $ 147.81 $ 147.81

ThisHMOisnotauthorizedtoacceptemployeesinbargaining 2 $ 151.76 $ 439.46 $ 295.61 $ 295.61

unitsW22andW41(UAW)asnewmembers.However, 3 $ 133.55 $ 386.73 $ 260.14 $ 260.14

employeeswhoarealreadyenrolledmayremainenrolled. 4 $ 209.42 $ 606.46 $ 407.94 $ 407.94

HealthAlliancePlan 1 $ 38.11 $ 215.98 $ 127.05 $ 127.05

2 $ 76.55 $ 433.81 $ 255.18 $ 255.18

3 $ 67.33 $ 381.53 $ 224.43 $ 224.43

4 $ 105.77 $ 599.36 $ 352.56 $ 352.56

HealthPlusofMichigan 1 $ 39.90 $ 219.73 $ 129.81 $ 129.81

unitsW22andW41(UAW)insomezipcodesasnewmembers. 3 $ 70.22 $ 386.73 $ 228.47 $ 228.47

4 $ 110.11 $ 606.46 $ 358.29 $ 358.29

1 Part‐timeemployeeshiredafter1/1/2000whoseregularworkscheduleis40hoursorlessperbiweeklypayperiodpaypremiumsaccordingtocolumn(d).2 Healthoptionsare:1=Employeeonlycoverage,2=Employee&Spouse,3=Employee&Child(ren),4=FullFamily.3 Employeeswhooptoutofhealthcoverage(becausetheyhave“primary”coveragethroughanon‐Stateemployeeornon‐Stateretiredspouse)willreceivearebateidenticalto

theCatastrophicHealthPlan.

Rates: Judicial , AFSCME, MCO, & MSEA, prior to Apri l 1, 2010

FY2012‐2013GROUPINSURANCEPREMIUMRATESFOREMPLOYEESHIREDPRIORTOAPRIL1,2010,EFFECTIVEOCTOBER14,2012

BIWEEKLY1 BIWEEKLY Part‐timeemployees Option2 Employee State Employee State

McLarenHealthPlan 1 $ 34.50 $ 195.49 $ 115.00 $ 115.00

unitsW22andW41(UAW)asnewmembers. 3 $ 60.72 $ 344.07 $ 202.40 $ 202.40

4 $ 95.22 $ 539.57 $ 317.40 $ 317.40

PhysiciansHealthPlan 1 $ 41.55 $ 219.73 $ 130.64 $ 130.64

2 $ 83.10 $ 439.46 $ 261.28 $ 261.28

3 $ 73.12 $ 386.73 $ 229.92 $ 229.92

4 $ 114.67 $ 606.46 $ 360.57 $ 360.57

PriorityHealthPlan,West 1 $ 54.41 $ 219.73 $ 137.07 $ 137.07

2 $ 108.82 $ 439.46 $ 274.14 $ 274.14

3 $ 95.76 $ 386.73 $ 241.24 $ 241.24

4 $ 150.17 $ 606.46 $ 378.31 $ 378.31

PriorityHealthPlan,East 1 $ 54.41 $ 219.73 $ 137.07 $ 137.07

ThisHMOisnotauthorizedtoacceptemployeesinbargainingunits 2 $ 108.82 $ 439.46 $ 274.14 $ 274.14

W22andW41(UAW)insomezipcodesasnewmembers. 3 $ 95.76 $ 386.73 $ 241.24 $ 241.24

4 $ 150.17 $ 606.46 $ 378.31 $ 378.31

PriorityHealthPlan,South 1 $ 54.41 $ 219.73 $ 137.07 $ 137.07

2 $ 108.82 $ 439.46 $ 274.14 $ 274.14

3 $ 95.76 $ 386.73 $ 241.24 $ 241.24

4 $ 150.17 $ 606.46 $ 378.31 $ 378.31

TotalHealthCare 1 $ 26.87 $ 152.27 $ 89.57 $ 89.57

2 $ 51.06 $ 289.32 $ 170.19 $ 170.19

3 $ 61.81 $ 350.23 $ 206.02 $ 206.02

4 $ 72.55 $ 411.14 $ 241.85 $ 241.85

VISIONPLANS

StateVisionPlan 1 $ ‐ $ 2.80 $ 1.40 $ 1.40

2 $ ‐ $ 4.93 $ 2.46 $ 2.46

3 $ ‐ $ 6.02 $ 3.01 $ 3.01

4 $ ‐ $ 8.16 $ 4.08 $ 4.08

DeclineVisionInsurance (n/a) (n/a) (n/a) (n/a) (n/a)

DENTALPLANS

StateDentalPlan 1 $ 1.08 $ 20.48 $ 10.78 $ 10.78

2 $ 1.97 $ 37.38 $ 19.67 $ 19.67

3 $ 2.40 $ 45.52 $ 23.96 $ 23.96

4 $ 3.28 $ 62.36 $ 32.82 $ 32.82

PreventiveDentalPlan 1 $ ‐ $ 2.99 $ 1.50 $ 1.50

EmployeesinthePreventiveDentalplanwillreceive 2 $ ‐ $ 5.21 $ 2.61 $ 2.61

a$100.00lumpsumpaymentonNovember8,2012. 3 $ ‐ $ 5.21 $ 2.61 $ 2.61

4 $ ‐ $ 7.42 $ 3.71 $ 3.71

MidwesternDentalPlan(DMO) 1 $ ‐ $ 15.99 $ 8.00 $ 8.00

2 $ ‐ $ 15.99 $ 8.00 $ 8.00

3 $ ‐ $ 15.99 $ 8.00 $ 8.00

4 $ ‐ $ 15.99 $ 8.00 $ 8.00

DeclineDentalInsurance3 (n/a) (n/a) (n/a) (n/a) (n/a)

1 Part‐timeemployeeshiredafter1/1/2000whoseregularworkscheduleis40hoursorlessperbiweeklypayperiodpaypremiumsaccordingtocolumn(d).2 Health,dentalandvisionoptionsare:1=Employeeonlycoverage,2=Employee&Spouse,3=Employee&Child(ren),4=FullFamily.3 Employeeswhooptoutofdentalcoverage(becausetheyhave“primary”coveragethroughanon‐Stateemployeeornon‐Stateretiredspouse)willreceivearebateidenticalto

thePreventiveDentalPlan.

Rates - Life Insurance & Long Term Disabil i ty

FY2012‐2013GROUPINSURANCEPREMIUMRATESFORLIFEINSURANCE—ALLEMPLOYEESEffectiveOctober14,2012

BIWEEKLY Option Employee StatePLANNAME/CODE (a) (b) (c)

LIFEINSURANCEPLANS

DependentLifeOptions

Spouse$1,500and/orChild(ren)$1,000 F $ 0.20 $0.00

Spouse$5,000and/orChild(ren)$2,500 G $ 0.60 $0.00

Spouse$10,000and/orChild(ren)$5,000 H $ 1.20 $0.00

Spouse$25,000and/orChild(ren)$10,000 K $ 4.00 $0.00

Child(ren)Only$10,000 L $ 0.75 $0.00

EmployeeLifeOptions

TheEmployeeOnlyregularplanis2timesyourannualsalary,uptoamaximumof$200,000.TheStatepays100%ofthepremiumforthisplan.

TheEmployeeOnlyreducedplanis1timesyourannualsalary,uptoamaximumof$50,000.EmployeesenrolledinthisplanwillreceiveabiweeklyrebatebeginningOctober25,2012. OfficeoftheStateEmployer,EmployeeHealthManagement

FY2012‐2013BIWEEKLYLONGTERMDISABILITYPREMIUMRATES—ALLEMPLOYEESRatesper$100ofEarnings*

EffectiveOctober14,2012

Status Employee State

PLANNAME (a) (b) (c)

AllemployeesexceptthoserepresentedbybargainingunitsW22andW41(UAW)

YIA0:Lessthan184hourssickleave PlanI $ 2.08 $ 0.92

YIA1:184‐527hourssickleave PlanIIA $ 0.53 $ 0.92

YIA2:528hoursormoresickleave PlanIIB $ 0.00 $ 0.92

YIA3:ReachPlanII(YIA1)butnowlessthan184hourssickleave PlanIIC $ 1.74 $ 0.92

EmployeesrepresentedbybargainingunitsW22andW41(UAW)

CalculationofEmployeeContribution:BiweeklyContribution=HourlyRatetimes2088,dividedby26,dividedby100,timestheEmployeeRateperPlan(I,IIA,IIB,orIIC)

*BenefitsaresubjecttomaximumsintheLTDbooklet.

YIA3:ReachPlanII(YIA1)butnowlessthan184hourssickleave PlanIIC$ 1.79$ 0.92

EndofRatesforJudicialBranchandBargainingUnits:MSEA(A02,A31),MCO(C12)and

AFSCME(U11)

Rates: Judicial Branch, AFSCME, MCO & MSEA, Hired on or af ter April 1, 2010

FY2012‐2013GROUPINSURANCEPREMIUMRATESFOREMPLOYEESHIREDONORAFTERAPRIL1,2010,EFFECTIVEOCTOBER14,2012

ForJudicialBranchandBargainingUnits:MSEA(A02,A31),MCO(C12),AFSCME(U11)Note:WhenchoosingaHMOorDMOplan,besuretoreviewavailabilityinyourarea.TheZipCodeListisavailableat

www.michigan.gov/employeebenefits.ChooseInsuranceOpenEnrollment.

HEALTHPLANS

NewStateHealthPlanPPO 1 $ 48.65 $ 194.61 $ 121.63 $ 121.63 2 $ 97.31 $ 389.24 $ 243.28 $ 243.28

3 $ 85.63 $ 342.53 $ 214.08 $ 214.08

4 $ 134.29 $ 537.15 $ 335.72 $ 335.72

EmployeeorSpousewithMedicare(Statepays100%)

CatastrophicHealthPlan 1 $ ‐ $ 15.81 $ 7.91 $ 7.91

EmployeesintheCatastrophicHealthPlanwillreceivea 2 $ ‐ $ 31.62 $ 15.81 $ 15.81

$50rebatewitheachpaycheckbeginningOctober25,2012. 3 $ ‐ $ 31.62 $ 15.81 $ 15.81

4 $ ‐ $ 31.62 $ 15.81 $ 15.81

DeclineHealthInsuranceCoverage3 (n/a)

NewBlueCareNetwork,Mid‐Michigan 1 $ 38.68 $ 194.61 $ 116.65 $ 116.65

2 $ 77.35 $ 389.24 $ 233.29 $ 233.29

3 $ 68.07 $ 342.53 $ 205.30 $ 205.30

4 $ 106.74 $ 537.15 $ 321.95 $ 321.95

NewBlueCareNetwork,EastMichigan 1 $ 34.86 $ 194.61 $ 114.74 $ 114.74

2 $ 69.71 $ 389.24 $ 229.48 $ 229.48

3 $ 61.35 $ 342.53 $ 201.94 $ 201.94

4 $ 96.21 $ 537.15 $ 316.68 $ 316.68

NewBlueCareNetwork,GreatLakesWest 1 $ 38.94 $ 194.61 $ 116.77 $ 116.77

2 $ 77.86 $ 389.24 $ 233.55 $ 233.55

3 $ 68.52 $ 342.53 $ 205.52 $ 205.52

4 $ 107.44 $ 537.15 $ 322.30 $ 322.30

NewBlueCareNetwork,SoutheastMichigan 1 $ 36.24 $ 194.61 $ 115.42 $ 115.42

2 $ 72.46 $ 389.24 $ 230.85 $ 230.85

3 $ 63.76 $ 342.53 $ 203.15 $ 203.15

4 $ 99.99 $ 537.15 $ 318.57 $ 318.57

NewGrandValleyHealthPlan 1 $ 28.77 $ 163.02 $ 95.89 $ 95.89

W22andW41(UAW)asnewmembers.However,employeeswho 3 $ 50.63 $ 286.91 $ 168.77 $ 168.77

arealreadyenrolledmayremainenrolled. 4 $ 79.40 $ 449.92 $ 264.66 $ 264.66

NewHealthAlliancePlan 1 $ 32.43 $ 183.76 $ 108.09 $ 108.09

2 $ 65.14 $ 369.10 $ 217.12 $ 217.12

3 $ 57.29 $ 324.62 $ 190.95 $ 190.95

4 $ 89.99 $ 509.96 $ 299.98 $ 299.98

NewHealthPlusofMichigan 1 $ 33.21 $ 188.21 $ 110.71 $ 110.71

W22andW41(UAW)insomezipcodesasnewmembers. 3 $ 58.46 $ 331.25 $ 194.85 $ 194.85

4 $ 91.67 $ 519.46 $ 305.56 $ 305.56

1 Part‐timeemployeeshiredafter1/1/2000(1/1/2002forMSEArepresentedbargainingunitsA02andA31)whoseregularworkscheduleis40hoursorlessperbiweeklypayperiodpaypremiumsaccordingtocolumn(d).

2 Healthoptionsare:1=Employeeonlycoverage,2=Employee&Spouse,3=Employee&Child(ren),4=FullFamily.3Employeeswhooptoutofhealthcoverage(becausetheyhave“primary”coveragethroughanon‐Stateemployeeornon‐Stateretiredspouse)willreceivearebateidenticalto

theCatastrophicHealthPlan.

Rates: Judicial , AFSCME, MCO & MSEA, Hired on or af ter Apri l 1, 2010

FY2012‐2013GROUPINSURANCEPREMIUMRATESFOREMPLOYEESHIREDONORAFTERAPRIL1,2010,EFFECTIVEOCTOBER14,2012

NewMcLarenHealthPlan 1 $ 28.52 $ 161.62 $ 95.07 $ 95.07

unitsW22andW41(UAW)asnewmembers. 3 $ 50.20 $ 284.48 $ 167.34 $ 167.34

4 $ 78.72 $ 446.08 $ 262.40 $ 262.40

NewPhysiciansHealthPlan 1 $ 27.79 $ 157.47 $ 92.63 $ 92.63

2 $ 55.58 $ 314.94 $ 185.26 $ 185.26

3 $ 48.91 $ 277.15 $ 163.03 $ 163.03

4 $ 76.70 $ 434.62 $ 255.66 $ 255.66

NewPriorityHealthPlan,West 1 $ 34.97 $ 194.61 $ 114.79 $ 114.79

2 $ 69.92 $ 389.24 $ 229.58 $ 229.58

3 $ 61.53 $ 342.53 $ 202.03 $ 202.03

4 $ 96.49 $ 537.15 $ 316.82 $ 316.82

NewPriorityHealthPlan,East 1 $ 34.97 $ 194.61 $ 114.79 $ 114.79

unitsW22andW41(UAW)insomezipcodesasnewmembers. 3 $ 61.53 $ 342.53 $ 202.03 $ 202.03

4 $ 96.49 $ 537.15 $ 316.82 $ 316.82

NewPriorityHealthPlan,South 1 $ 34.97 $ 194.61 $ 114.79 $ 114.79

2 $ 69.92 $ 389.24 $ 229.58 $ 229.58

3 $ 61.53 $ 342.53 $ 202.03 $ 202.03

4 $ 96.49 $ 537.15 $ 316.82 $ 316.82

VISIONPLANS

StateVisionPlan 1 $ ‐ $ 2.80 $ 1.40 $ 1.40

2 $ ‐ $ 4.93 $ 2.46 $ 2.46

3 $ ‐ $ 6.02 $ 3.01 $ 3.01

4 $ ‐ $ 8.16 $ 4.08 $ 4.08

DeclineVisionInsurance (n/a) (n/a) (n/a) (n/a)

DENTALPLANS

2 $ 1.97 $ 37.38 $ 19.67 $ 19.67

3 $ 2.40 $ 45.52 $ 23.96 $ 23.96

4 $ 3.28 $ 62.36 $ 32.82 $ 32.82

PreventiveDentalPlan 1 $ ‐ $ 2.99 $ 1.50 $ 1.50

EmployeesinthePreventiveDentalplanwillreceive 2 $ ‐ $ 5.21 $ 2.61 $ 2.61

a$100.00lumpsumpaymentonNovember8,2012. 3 $ ‐ $ 5.21 $ 2.61 $ 2.61

4 $ ‐ $ 7.42 $ 3.71 $ 3.71

MidwesternDentalPlan(DMO) 1 $ ‐ $ 15.99 $ 8.00 $ 8.00

2 $ ‐ $ 15.99 $ 8.00 $ 8.00

3 $ ‐ $ 15.99 $ 8.00 $ 8.00

4 $ ‐ $ 15.99 $ 8.00 $ 8.00

DeclineDentalInsurance3 (n/a) (n/a) (n/a) (n/a) (n/a)

NewTotalHealthCare 1 $ 24.69 $ 139.88 $ 82.28 $ 82.28

2 $ 56.78 $ 321.73 $ 189.25 $ 189.25

4 $ 66.65 $ 377.68 $ 222.16 $ 222.16

3 $ 46.90 $ 265.78 $ 156.34 $ 156.34

1 Part‐timeemployeeshiredafter1/1/2000whoseregularworkscheduleis40hoursorlessperbiweeklypayperiodpaypremiumsaccordingtocolumn(d).2 Health,dentalandvisionoptionsare:1=Employeeonlycoverage,2=Employee&Spouse,3=Employee&Child(ren),4=FullFamily.3 Employeeswhooptoutofdentalcoverage(becausetheyhave“primary”coveragethroughanon‐Stateemployeeornon‐Stateretiredspouse)willreceivearebateidenticalto

thePreventiveDentalPlan.

Rates - Life Insurance & Long Term Disabil i ty

FY2012‐2013GROUPINSURANCEPREMIUMRATESFORLIFEINSURANCE—ALLEMPLOYEES

BIWEEKLY Option Employee StatePLANNAME (a) (b) (c)

LIFEINSURANCEPLANS

Spouse$1,500and/orChild(ren)$1,000 F $ 0.20 $0.00

Spouse$5,000and/orChild(ren)$2,500 G $ 0.60 $0.00

Spouse$10,000and/orChild(ren)$5,000 H $ 1.20 $0.00

Spouse$25,000and/orChild(ren)$10,000 K $ 4.00 $0.00

Child(ren)Only$10,000 L $ 0.75 $0.00

EmployeeLifeOptions

TheEmployeeOnlyregularplanis2timesyourannualsalary,uptoamaximumof$200,000.TheStatepays100%ofthepremiumforthisplan.

TheEmployeeOnlyreducedplanis1timesyourannualsalary,uptoamaximumof$50,000.EmployeesenrolledinthisplanwillreceiveabiweeklyrebatebeginningOctober25,2012.

OfficeoftheStateEmployer,EmployeeHealthManagement

FY2012‐2013BIWEEKLYLONGTERMDISABILITYPREMIUMRATES—ALLEMPLOYEESRatesper$100ofEarnings*

Status Employee State

PLANNAME (a) (b) (c)

AllemployeesexceptthoserepresentedbybargainingunitsW22andW41(UAW)

YIA3:ReachPlanII(YIA1)butnowlessthan184hourssickleave PlanIIC $ 1.74 $ 0.92

EmployeesrepresentedbybargainingunitsW22andW41(UAW)

CalculationofEmployeeContribution:BiweeklyContribution=HourlyRatetimes2088,dividedby26,dividedby100,timestheEmployeeRateperPlan(I,IIA,IIB,orIIC)

*BenefitsaresubjecttomaximumsintheLTDbooklet.

YIA3:ReachPlanII(YIA1)butnowlessthan184hourssickleave PlanIIC$ 1.79$ 0.92

EndofRatesforJudicialBranchandBargainingUnits:MSEA(A02,A31),MCO(C12),

AFSCME(U11)

COBRA - Judicial Branch, AFSCME, MCO & MSEA

FY2012‐2013COBRAPREMIUMRATESEFFECTIVEOCTOBER1,2012

Note:WhenchoosingaHMOorDMOplan,besuretoreviewavailabilityinyourarea.TheZipCodeListisavailableatwww.michigan.gov/employeebenefits.ChooseInsuranceOpenEnrollment.

HiredPriortoApril1,2010

HiredOnorAfterApril1,2010

MONTHLYPREMIUM MONTHLYPREMIUM

Option1 Leave/Layoff(100%)

COBRA(102%)

Leave/Layoff(100%)

COBRA(102%)

HEALTHPLANS

StateHealthPlanPPO 1 $ 595.11 $ 607.01 $ 527.08 $ 537.62 2 $ 1,190.21 $ 1,214.02 $ 1,054.19 $ 1,075.28 3 $ 1,047.39 $ 1,068.34 $ 927.69 $ 946.24

4 $ 1,642.50 $ 1,675.35 $ 1,454.78 $ 1,483.88

5 $ 476.09 $ 485.61 $ 421.66 $ 430.09

6 $ 952.17 $ 971.21 $ 843.35 $ 860.22

7 $ 837.91 $ 854.67 $ 742.15 $ 756.99

8 $ 1,314.00 $ 1,340.28 $ 1,163.83 $ 1,187.10

CatastrophicHealthPlan 1 $ 34.26 $ 34.93 $ 34.26 $ 34.93

2 $ 68.51 $ 69.88 $ 68.51 $ 69.81

3 $ 68.51 $ 69.88 $ 68.51 $ 69.81

4 $ 68.51 $ 69.88 $ 68.51 $ 69.81

BlueCareNetwork,Mid‐Michigan 1 $ 588.83 $ 600.61 $ 505.47 $ 515.58

2 $ 1,177.66 $ 1,201.21 $ 1,010.94 $ 1,031.16

3 $ 1,036.34 $ 1,057.07 $ 889.63 $ 907.42

4 $ 1,625.17 $ 1,657.67 $ 1,395.10 $ 1,423.00

BlueCareNetwork,EastMichigan 1 $ 593.69 $ 605.56 $ 497.20 $ 507.14

2 $ 1,187.37 $ 1,211.12 $ 994.40 $ 1,014.29 3 $ 1,044.89 $ 1,065.79 $ 875.07 $ 892.57 4 $ 1,638.58 $ 1,671.35 $ 1,372.27 $ 1,399.72

BlueCareNetwork,GreatLakesWest 1 $ 593.67 $ 605.54 $ 506.02 $ 516.14

2 $ 1,187.35 $ 1,211.10 $ 1,012.04 $ 1,032.28

3 $ 1,044.87 $ 1,065.77 $ 890.60 $ 908.41

4 $ 1,638.54 $ 1,671.31 $ 1,396.62 $ 1,424.55

BlueCareNetwork,SoutheastMichigan 1 $ 586.07 $ 597.79 $ 500.17 $ 510.77

2 $ 1,172.15 $ 1,195.59 $ 1,000.34 $ 1,020.35

3 $ 1,031.49 $ 1,052.12 $ 880.30 $ 897.91

4 $ 1,617.56 $ 1,649.91 $ 1,380.47 $ 1,408.08

GrandValleyHealthPlan 1 $ 640.49 $ 653.30 $ 415.53 $ 423.84

2 $ 1,280.98 $ 1,306.60 $ 831.06 $ 847.68

3 $ 1,127.26 $ 1,149.81 $ 731.33 $ 745.96

4 $ 1,767.75 $ 1,803.11 $ 1,146.86 $ 1,169.80

HealthAlliancePlan 1 $ 550.53 $ 561.54 $ 468.41 $ 477.78

2 $ 1,105.78 $ 1,127.90 $ 940.85 $ 959.67

3 $ 972.53 $ 991.98 $ 827.47 $ 844.02

4 $ 1,527.78 $ 1,558.34 $ 1,299.91 $ 1,325.91

HealthPlusofMichigan 1 $ 562.53 $ 573.78 $ 479.75 $ 489.35

2 $ 1,125.06 $ 1,147.56 $ 959.50 $ 978.69

3 $ 990.05 $ 1,009.85 $ 844.36 $ 861.25 4 $ 1,552.58 $ 1,583.63 $ 1,324.11 $ 1,350.59

1 Healthoptionsare:1=Employeeonlycoverage,2=Employee&Spouse,3=Employee&Child(ren),4=FullFamily, 5=EmployeeOnlyw/Medicare,6=Employee&Spousew/Medicare,7=Employeew/Medicare&Children,8=FullFamilyw/Medicare.

COBRA - Judicial Branch, AFSCME, MCO & MSEA

FY2012‐2013COBRAPREMIUMRATESEFFECTIVEOCTOBER1,2012

HiredPriortoApril1,2010

HiredOnorAfterApril1,2010

MONTHLYPREMIUM MONTHLYPREMIUM

Option1 Leave/Layoff(100%)

COBRA(102%)

Leave/Layoff(100%)

COBRA(102%)

McLarenHealthPlan 1 $ 498.32 $ 508.29 $ 411.96 $ 420.20

2 $ 996.65 $ 1,016.58 $ 823.95 $ 840.43

3 $ 877.05 $ 894.59 $ 725.14 $ 739.64

4 $ 1,375.38 $ 1,402.89 $ 1,137.06 $ 1,159.80

PhysiciansHealthPlan 1 $ 566.11 $ 577.43 $ 401.40 $ 409.43

2 $ 1,132.21 $ 1,154.85 $ 802.80 $ 818.86

3 $ 996.34 $ 1,016.27 $ 706.46 $ 720.59

4 $ 1,562.45 $ 1,593.70 $ 1,107.86 $ 1,130.02

PriorityHealthPlan,West 1 $ 593.97 $ 605.85 $ 497.42 $ 507.37

2 $ 1,187.94 $ 1,211.70 $ 994.84 $ 1,014.74

3 $ 1,045.39 $ 1,066.30 $ 875.46 $ 892.97

4 $ 1,639.36 $ 1,672.15 $ 1,372.88 $ 1,400.34

PriorityHealthPlan,East 1 $ 593.97 $ 605.85 $ 497.42 $ 507.37

2 $ 1,187.94 $ 1,211.70 $ 994.84 $ 1,014.74

3 $ 1,045.39 $ 1,066.30 $ 875.46 $ 892.97

4 $ 1,639.36 $ 1,672.15 $ 1,372.88 $ 1,400.34

PriorityHealthPlan,South 1 $ 593.97 $ 605.85 $ 497.42 $ 507.37

2 $ 1,187.94 $ 1,211.70 $ 994.84 $ 1,014.74

3 $ 1,045.39 $ 1,066.30 $ 875.46 $ 892.97

4 $ 1,639.36 $ 1,672.15 $ 1,372.88 $ 1,400.34

TotalHealthCare 1 $ 388.15 $ 395.91 $ 356.56 $ 363.69

2 $ 737.49 $ 752.24 $ 820.09 $ 836.49

3 $ 892.75 $ 910.61 $ 677.47 $ 691.02

4 $ 1,048.01 $ 1,068.97 $ 962.71 $ 981.96

VISIONPLANS

StateVisionPlan 1 $ 6.08 $ 6.20 $ 6.08 $ 6.20

2 $ 10.67 $ 10.90 $ 10.67 $ 10.90

3 $ 13.04 $ 13.30 $ 13.04 $ 13.30

4 $ 17.67 $ 18.02 $ 17.67 $ 18.02

DENTALPLANS

2 $ 85.25 $ 86.96 $ 85.25 $ 86.96

3 $ 103.83 $ 105.89 $ 103.83 $ 105.89

4 $ 142.22 $ 145.06 $ 142.22 $ 145.06

PreventiveDentalPlan 1 $ 6.48 $ 6.61 $ 6.48 $ 6.61

2 $ 11.29 $ 11.50 $ 11.29 $ 11.50

3 $ 11.29 $ 11.50 $ 11.29 $ 11.50

4 $ 16.08 $ 16.40 $ 16.08 $ 16.40

MidwesternDentalPlan(DMO) 1 $ 34.65 $ 35.34 $ 34.65 $ 35.34

2 $ 34.65 $ 35.34 $ 34.65 $ 35.34

3 $ 34.65 $ 35.34 $ 34.65 $ 35.34

4 $ 34.65 $ 35.34 $ 34.65 $ 35.34

1 Healthoptionsare:1=Employeeonlycoverage,2=Employee&Spouse,3=Employee&Child(ren),4=FullFamily

COBRA - Life Insurance

FY2012‐2013COBRAPREMIUMRATESFORLIFEINSURANCEALLEMPLOYEES

MONTHLYPREMIUM

PLANNAME Option Leave/Layoff(100%)

COBRA(102%)

LIFEINSURANCEPLANS

Spouse$1,500and/orChild(ren)$1,000 F $ 0.43 $(n/a)

Spouse$5,000and/orChild(ren)$2,500 G $ 1.30 $(n/a)

Spouse$10,000and/orChild(ren)$5,000 H $ 2.60 $(n/a)

Spouse$25,000and/orChild(ren)$10,000 K $ 8.67 $(n/a)

Child(ren)Only$10,000 L $ 1.63 $(n/a)

EmployeeLifeOptions

EmployeeLifeOnly(Fire&RescueEmployeesOnly) $ 0.56/$1,000 $(n/a)

EmployeeLifeOnly E $ 0.46/$1,000 $(n/a)

1 Healthoptionsare:1=Employeeonlycoverage,2=Employee&Spouse,3=Employee&Child(ren),4=FullFamily

EndofRatesCOBRAPREMIUMRATES

ForJudicialBranchandBargainingUnits:JudicialBranch,MSEA(A02,A31),MCO(C12),AFSCME(U11)

JUDICIALEMPLOYEEBENEFITSSUMMARY

MailingAddress:P.O.Box30052

Lansing,MI48909

JudicialHumanResources

(517)373‐1147Fax:(517)373‐5019

HoursofOperation

8:00a.m.to5:00p.m.MondaythroughFriday(exceptonstateholidays)

EmployeeBenefitsDivisionWebsitewww.michigan.gov/employeebenefits

JudicialSelf‐ServiceGateway

andMIHRInformationhttp://www.courts.mi.gov/selfserv/

State of Michigan Employee Benefits Summary For Judicial … · 2012-09-28 · Dental Care Options...

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