Brigham City Corp. · Enrollment Guidelines General Information 1-2 Altius Health Plans Medical 800.377.4161 Procedures for Enrolling Transamerica 2-3 TransConnect / Critical Assistance

Employee Benefits 2011

This publication is only a partial summary of benefits by Sterling Benefits and is provided for informational purposes only. It does not describe all elements of the summarized programs. For complete information

regarding the benefits, plan provisions, limitations and exclusions, and for a description of grievance procedures and binding arbitration of disputes, refer to the subscriber certificate that will be provided to you after

enrollment. In the event of a discrepancy or conflict between the information contained in this publication and the benefit plan provisions, the plan documents and insurance contracts will govern. Copies of these

documents are available for your review from your Human Resources Department. No rights shall accrue to you and/or your dependents because of any statement, error or omission in this publication.

Brigham City Corp.

January 1st, 2011 to December 31st, 2011 Corrected

What’s Inside: Contact Information:

Enrollment Guidelines

General Information

1-2 Altius Health Plans Medical

800.377.4161

Procedures for Enrolling

2-3 Transamerica TransConnect / Critical Assistance

800.251.7254

Medical Coverage – Altius

4-10 Assurant Employee Benefits Dental

800.733.7879

Gap & Critical Illness –

Transamerica

11-12 Vision

Hartford Life Life, STD, LTD

800.877.7195

800.752.9713

Dental & Vision – Assurant

Life, STD, LTD – Hartford Life

13-15

16-21

NBSI Cafeteria Plan

Sterling Benefits Jimmie Jones

800.274.0503

435.723.7144

Section 125 – Cafeteria Plan 22-23 Ann Green 801.269.6798

Important Notices

Employee Website Instructions

24-37 Toll Free

Fax

866.884.6762

801.269.6767

Please contact your Benefits Administrator…. …..for questions about benefits and contributions, enrollment questions, benefit change forms, notifications for changes in status, provider directories and other general carrier information.

Email: [email protected] [email protected]

mailto:[email protected]


ENROLLMENT GUIDELINES

Once the Enrollment Period Has Ended, You May Not Change Your Benefit Elections

When you have a

qualifying change in

employment or family

status you have

30 days to complete and return

a new enrollment form

Benefits open enrollment for

Brigham City Corp. will be held

each year. Until the enrollment

deadline you may change your

benefit elections as you desire. All

employee premiums for healthcare

coverage can be deducted from

payroll on a pretax basis.

After the enrollment deadline, elections may be altered

only when you have a qualifying change in

employment or family status. You have 30 days to

complete and return a new enrollment form to Human

Resources. Otherwise, elections you make now will

stay in effect for the entire plan year.

Eligibility:

Eligible employees must work 30 + hours/week;

Employees will receive benefits once the new hire

waiting period has been satisfied (provided that

forms are properly submitted). See Human

Resources for details.

Employees will receive coverage for dependents to

age 26 if coverage isn’t available through their

work, regardless of their marital status. Please refer

to your summary plan description’s definition of

dependent.

Employees hired after the plan year begins will

select their coverage choices for the remainder of

that plan year at the time of eligibility. All the

necessary enrollment and change forms are

available through the Human Resources

Department.

Qualifying Changes (30 day deadline): You get married, legally separated or divorced;

You add a dependent child through birth, adoption

or change in custody;

Your spouse or child dies;

Your work schedule changes, affecting benefits,

i.e. reduction or increase in hours, affecting

eligibility;

Your spouse begins or terminates employment,

affecting benefit coverage;

Your dependent loses eligibility for coverage;

Your spouse involuntarily loses health coverage

through his/her employer;

You and/or your spouse and dependents become

eligible for COBRA / State Extension;

You and/or your spouse and dependants gain or

lose Medicaid coverage;

You receive a Qualified Medical Child Support

Order (QMCSO)

FEDERAL PRIVACY ACT GUIDELINES

Privacy of Personal Health Information

As of April 14th, 2004, many employers in the U.S., including our company, are required to adhere to

privacy rules regarding their employees’ personal health information. The Health Insurance Portability

and Accountability Act (HIPAA) require employers to adhere to strict privacy guidelines. This act

establishes employees’ rights with regard to their personal health information.

Employers may implement the HIPAA guidelines using one of two approaches: “Hands-On” and “Hands-

Off” of employees’ personal health information. An employer who adopts a Hands-On approach is

granted access to all of their employees’ personal health information, and accordingly is required to

adhere to all of the HIPAA privacy rules. An employer who adopts a Hands-Off approach chooses to not

have access to its employees’ personal health information, and is thus required to follow only a limited

portion of the HIPAA privacy rules. Please contact the Human Resources or Benefits Department to find

out which approach our company adopts.

We feel it is vitally important that your personal health information remain private. If you have any

questions regarding this federal regulation, you are welcome to speak with our Sterling Benefits

Representative or contact human resources.

GENERAL INFORMATION

MEDICAL – Altius Health Plans

Brigham City Corp. is again offering the Peak Plus Plan through Altius Health Plans. The Peak Plus Plan is a

PPO plan and allows you the freedom to visit any doctor you wish. With the Peak Premier network of providers,

you have the choice of over 4,500 participating providers and 36 participating hospitals. With this plan you do

not need to select a primary care physician (PCP) or receive a referral from a PCP to see a specialist. At the time

you need services; you will simply select any participating provider. You also have the protection of worldwide

coverage for urgent or emergency care.

Benefit Type 2010 Benefits 2011 Benefits Deductible – no change! $2,000 / $4,000 $2,000 / $4,000

Office Visit Copay - PCP/Spl $20 / $20 $25 / $40

Urgent Care / ER $30 / $100 $40 / $150

Rx Card $10/25/50 $15/30/60

DENTAL and VISION – Assurant

Your dental coverage will be provided through Assurant Employee Benefits. There are no changes in the dental

benefits; you will still have the freedom to choose any licensed dentist. The preferred provider network for this

plan is called Dental Health Alliance (DHA) which has one of the largest national PPO networks of 110,000+

providers; there are approximately 1400+ participating dentists in Utah, with 23 in Brigham City. Participating

dentists agree to charge DHA members their negotiated network fees on covered services, which may result in

cost savings for you and your covered dependents. Please refer to the benefit summary printed in this booklet for

more information on the In and Out of Network benefits.

Your dental plan includes a vision discount plan through Vision Service Plan (VSP). This vision plan includes

discounts on exams (including contact lens exams) and the purchase of eyeglasses, sunglasses and other

prescription eyewear when provided by VSP doctors. VSP is available for you and everyone covered on your

dental plan. Please refer to the vision discounts outline included in this booklet.

LIFE, AD&D, STD, LTD, Supplemental Life – Hartford Life Group Life Insurance - Brigham City Corp. provides $50,000 of group life and AD & D coverage through

Hartford Life for all eligible employees and dependent life coverage of $5,000 on your spouse and $2,000 on

each eligible dependent child. This is 100% employer paid.

Short Term Disability – Brigham City Corp. provides employer paid short-term disability insurance coverage

that would pay you a benefit of 66.67% of your weekly earnings. The maximum you would receive is $1,250

per week. Once approved, benefits are payable beginning on the 4th day after your accident or 4

th day of sickness

and can continue for up to 13 weeks.

Long Term Disability - Brigham City Corp. provides employer paid long-term disability coverage which will

pay up to 66.67% of your earnings to a maximum monthly benefit of $8,000 per month. You must be disabled

for at least 90 days before you receive employer paid LTD benefits. Please see the Summary of Group Long

Term and Short Term Disability Insurance Benefits for more information.

Supplemental Life – Brigham City Corp. makes available supplemental life coverage for you and your eligible

dependents. This is a voluntary benefit with premiums being paid through payroll deduction. Please contact

Human Resources for rates and enrollment information.

GAP COVERAGE and CRITICAL ILLNESS – Transamerica

Your employer is providing you with a group comprehensive medical program designed to cover serious illness

or injury that contains deductibles, coinsurance and co-payments for which you are responsible. TransConnect

has been specifically created to help cover out-of-pocket expenses of deductibles, coinsurance and co-payments.

This plan will pay up to $4,000 for In-Patient and $2,000 for Outpatient.

After the waiting period, CriticalAssistance Select offers benefits to help with the costs associated with critical

illness when you or your insured loved ones are initially diagnosed with the following conditions: cancer, heart

attach, stroke and end-stage renal failure. It even provides benefits for major organ transplant surgery! This

benefit is payable one time for each covered person.

SECTION 125 Cafeteria Plan

Brigham City Corp. is offering a Section 125 Cafeteria Plan. This is a significant benefit because it will enable

employees to received 100% deduction of approved expenses on a pre-tax payroll basis. If you participate, you

may elect to have a specified amount of pretax money deducted from your paycheck each pay period for

premiums, health care reimbursement for certain out-of-pocket medical, dental, vision and/or hearing expenses,

and dependent care reimbursed for qualified child care payments. The value of this benefit depends on your

individual tax bracket. In general, most employees will increase take home pay by approximately 30% of the

amount of premium you have deducted for benefits.

Please Note: Flexible Spending Accounts (FSA – aka Cafeteria Plans) may no longer be used to purchase over-the-counter drugs unless prescribed by a doctor. This includes, but is not limited to, contact lens solution, cold medication, Band-Aids, etc. that you’ve been able to purchase in the past with FSA dollars. Please keep this in mind when calculating your medical expenses for 2011.

Claims and Appeals: Altius is responsible for evaluating all benefit claims under the Brigham City Corp. Plan.

Altius will decide your claim in accordance with its reasonable claims procedures, as required by ERISA. If

your claim is denied, you may appeal to Altius for a review of the denied claim and Altius will decide your

appeal in accordance with its reasonable procedures, as required by ERISA. Refer to the insurance carrier for

complete details regarding claims and appeals procedures.

ID Cards: You will be issued an ID cards after you enroll with Altius Health Plans, Assurant and Transamerica.

Please carry your ID cards with you and present it each time you receive service. If you lose your ID card, you

can request a new one by contacting the respective insurance carrier or go to Sterling Benefits website and link

over to the carrier website and order one online.

PROCEDURES FOR ENROLLING:

PLEASE NOTE: Please feel free to call us if you have questions concerning enrollment procedures or need insurance enrollment/change forms. You can obtain these by logging onto our website at www.sterlingbenefits.net, enter in the username and password found on page 3, click on “My Benefits” and go to procedures or forms. Detailed website instructions for employees are included with this booklet.

MEDICAL: If you are currently enrolled and are not changing your enrollment in any way, there is no need to

complete any forms. If you want to enroll under the Altius Peak Plus Plan you will need to complete the Large

Group Enrollment Form. If you are choosing not to enroll in the medical plan at this time, please complete the

Large Group Waiver Form. Again, please sign and date the form. Whether or not you enroll, your form must be

collected and kept on file.

DENTAL and VISION – Assurant

If you are currently enrolled on the previous dental/vision plan, there are no forms to complete. If enrolling on

the Assurant dental and VSP vision plan, please complete the Assurant dental enrollment form, sign and date;

you will automatically be enrolled on the vision plan. If you are not enrolling on the dental plan, please

complete the waiver section of the form. Whether you enroll or not, your form must be completed and kept on

file.

LIFE, AD&D, Supplemental Life, STD and LTD – Hartford

Your employer pays for your Life and AD&D, STD and LTD coverages. Please complete the Hartford Life

enrollment form and be sure to complete the beneficiary designation section of the enrollment form. Please sign

and date the form. Upon meeting your eligibility, you will automatically be enrolled on the STD and LTD

coverages.

http://www.sterlingbenefits.net/

CRITICAL ILLNESS and GAP COVERAGE: You must be enrolled on the group medical plan to be

eligible for the gap coverage and critical illness. Separate enrollment forms must also be completed and

submitted.

SECTION 125 Cafeteria Plan: If you are enrolling in the Section 125 Cafeteria Plan, you will need to

complete the Flex Benefit Employee Enrollment Form. This form is necessary to participate in the Cafeteria

Plan. If you choose not to participate, please contact your Human Resource Department and complete the

necessary waiver form.

CONTINUATION OF COVERAGE: If you elect Medical and/or Dental coverage and are covered for at

least one (1) day, you will have certain rights to continue your coverage upon your termination of employment.

Please see the Continuation of Coverage Rights section of this booklet.

PRE-EXISTING CONDITION LIMITATIONS: If you have had continuous coverage with less than a 63

day lapse between your prior coverage and your date of hire (not including your new hire waiting period); Pre-

Existing Condition Limitations do not apply. If there has been greater than a 63 day lapse (not including your

new hire waiting period), Pre-Existing Condition Limitations may apply. Please see the insurance company

information for specific details.

LATE ENROLLMENT: If an employee declines coverage when first eligible to enroll on the plan and later

chooses to enroll, the employee will be considered as a late enrollee. Such late enrollee will be subject to special

late enrollee rules of the plan. If an employee declines coverage in writing, and at a later date such employee

requests to be covered, such employee will be eligible to enroll during the following open enrollment period of

the plan. Such enrollees will be considered “late applicants” and will be subject to a pre-existing waiting period.

SPECIAL ENROLLMENT: If you are declining enrollment for yourself or your dependents (including your

spouse) because of other health insurance coverage, you may in the future be able to enroll yourself or your

dependents in this plan, provided that you request enrollment within 30 days after your other coverage ends. 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, provided that you request enrollment within 30 days after

the marriage, birth, adoption, or placement for adoption. FURTHERMORE, if you wish to add your new

dependent to your coverage you MUST complete election paperwork within 30 days from the date of the birth

or adoption.

Did you know you can find benefit summaries and enrollment/change forms online? Go to www.sterlingbenefits.net and use the username and password noted below!

Employee Login:

User name: brighamcc

Password: sbis

Enter

View Benefit Summaries

Find Procedures for Enrollment,

Changes, etc.

Access & Print Forms

Link to Preferred Providers

Read Recent Health Related

Articles

4525 South Wasatch Blvd.,

Suite #250

Salt Lake City, UT 84124

Phone: 801-269-6700

Fax: 801-269-6767

Toll Free: 866-884-6762


Getting the most out of your coverage with…

A new way to get the most out of your health care coverage, www.ahplans.com is a valuable online

resource to help improve health and well-being for Altius members. It is secure and easy to use.

Registering is simple. All you need is your Altius ID card and Netscape or Internet Explorer 4.0 or

higher. Once you register you will have instant access to your healthcare information. With Altius, you

can:

Search for providers Access Altius Health Library

View AltiusExtra - (value-added benefits) Access benefit information

View eligibility/request I.D. cards View the Altius Preferred Drug List

Review claims Order Prescription Drugs Online

provides access to discounts for Cosmetic Dentistry, Cosmetic

Dermatology, Cosmetic Surgery, Health Clubs, Hearing Aids, Lasik, Eyeglasses and Contacts,

Massage Therapy, Vitamins, and more. Plus, you’ll have access to Altius’ Library of health

information, access to Smoking Cessation and other Health Education classes.

Altius’ Mail Service Pharmacy

Easy process to use your mail service pharmacy program:

The service is fast and easy…

1. Telephone your doctor’s office and request a 90 day supply prescription.

To maximize your convenience, ask your physician to write your prescription for a 90-day supply with the maximum refills allowable.

2. Once you have obtained your new prescriptions, mail them with a completed order form to:

Medco Health Solutions of Forth Worth P. O. Box 650322

Dallas, TX 75265-0322

For customer service, please call the toll free number listed on your ID Card. OR

If you prefer using the internet for your refills, you may visit www.medco.com and follow their online directions. New

prescriptions must be mailed or phoned in by your physician.

Altius Mental Health Benefits – Mental health benefits are handled through MHNet.

To access the mental health care benefits, please call

(800) 701-8663

Altius Customer Service: 800-377-4161

For services and/or procedures requiring pre-authorization, Please call: 800-879-0234

Please understand with any benefit plan, Communication is the key to making sure you get the

best possible outcome. If you have questions regarding what your benefits are or want to know

how a particular procedure will be handled feel free to contact the respective carrier.

Or, call

Sterling Benefits – We’re here to help. If you find yourself in the middle of a sticky situation or you feel you are not being treated fairly please call us at 801.269-6700. Earlier is always better than later to include us and ensure a positive result!!

http://www.medco.com/

Copays apply to each visit. Medical services with fixed copays are not subject to deductible. Deductibles do not apply to the out-of-pocket maximum.Altius pays non-participating providers based on Eligible Medical Expenses. You are responsible for the difference between billed charges and your Eligible Medical Expenses inaddition to your share of coinsurance. This difference does not apply to the out-of-pocket maximum. Altius Customer Service 1-800-377-4161 www.altiushealthplans.com

* Applies to out-of-pocket maximum (OOPM), AD = after deductible, APD = after Pharmacy Deductible PPCMPOS3102 Rev. 10-10

1

ALTIUS PEAK PLUS PLANPP86 2000-25S-R15_30_60A-C80

Brigham CityJanuary 1, 2011

ParticipatingProviders

Non-ParticipatingProviders

DEDUCTIBLE, OUT-OF-POCKET & LIMITS

Calendar Year Deductible – (Individual / Family) Does not apply toOut-of-Pocket Maximum. Cumulative across benefit levels. $2,000 / $4,000 $4,000 / $8,000

Out-of-Pocket Maximum – (Individual / Family) Fixed dollar copays donot apply. Cumulative across benefit levels. $2,000 / $4,000 $3,000 / $6,000

Lifetime Maximum Unlimited

Pre-Existing Condition Limitation – Not applicable to membersunder age 19. 9 Months 12 Months

OUTPATIENT SERVICES YOU PAY

Preventive Care Services – When provided in conjunction with apreventive diagnosis, as determined by Altius, including annual adult physicalexaminations, well child care, family planning, hearing and vision exams, routineimmunizations, minor diagnostic laboratory tests, and colonoscopies. Some servicesyou receive during a preventive office visit may not qualify as Preventive CareServices and will be subject to applicable deductibles, copays, and/or coinsurance

You Pay Nothing 40%* AD

Office Visits – Primary Care $25 40%* AD

Office Visits – Specialty Care $40 40%* AD

After-Hours Care / Urgent Care – Care received in a physician’soffice or urgent care facility. $40 $80

Chiropractic Office Visits – Limited to 20 visits per member, percalendar year. $40

ParticipatingProviders Only

Eye Exams – Optometrist $25 40%* AD

Major Diagnostic Services – Sleep studies, laboratory tests andradiology, including, but not limited to CT scans and MRIs. 20%* AD 40%* AD

Minor Diagnostic Laboratory Tests and X-Rays – Including,but not limited to mammograms and chest X-rays. You Pay Nothing 40%* AD

Outpatient Hospital / Facility Services – Including, but not limitedto, outpatient surgery, observation, chemotherapy, radiation therapy, dialysis,cardiovascular services, infusion therapy, endoscopy, and pulmonary services.Includes physician charges. Cardiac rehabilitation and pulmonary rehabilitationlimited to a combined benefit of 18 outpatient facility visits per member, percalendar year.

20%* AD 40%* AD

Physiotherapy Services at a Provider's Office – Physical,occupational and speech therapy provided on an outpatient basis. Limited to acombined benefit of 20 provider's office and/or outpatient facility visits of each typeper member, per calendar year.

$40 40%* AD

Physiotherapy Services at an Outpatient Facility – Physical,occupational and speech therapy provided on an outpatient basis. Limited to acombined benefit of 20 provider's office and/or outpatient facility visits of each typeper member, per calendar year.

20%* AD 40%* AD

EMERGENCY CARE YOU PAY

Emergency Room Care – When medically necessary, as determined byAltius. Includes all services provided in an Emergency Room setting. Inpatientbenefit applies when admitted. Outpatient hospital benefit applies when transferredto an operating room.

$150 $150

Urgent Care – When medically necessary, as determined by Altius. $40 $80

Ambulance / Paramedics – (including Air Ambulance) When medicallynecessary, as determined by Altius. 20%* AD

ParticipatingBenefit Applies

http://www.altiushealthplans.com



2





INPATIENT SERVICES YOU PAY

Inpatient Hospital / Facility Services 20%* AD 40%* AD

Inpatient Physiotherapy Services – Physical, occupational andspeech therapy provided on an inpatient basis. Limited to 60 days per member, percalendar year for all therapy types combined.

20%* AD 40%* AD

Physician, Surgeon, Assistant Surgeon,Anesthesiologist

20%* AD 40%* AD

Organ Transplant Services – Organ and tissue transplant services,including, but not limited to, cornea, kidney, heart, lung, heart-lung, liver, pancreas,and bone marrow transplants and related services. Office visits and other servicesrelated to organ transplant may have an additional copay.

20%* ADParticipating

Providers Only

MATERNITY SERVICES YOU PAY

Pre-Natal and Post-Natal Care – Professional Services –Routine pre-natal office visits, delivery (including surgeon and assistant surgeon),and post-natal care. Regular benefits apply for complications of pregnancy.

20%* AD 40%* AD

Inpatient Hospital / Facility Services 20%* AD 40%* AD

Adoption Indemnity Benefit – Indemnity benefit for a child placed foradoption with the subscriber within 90 days of birth. The maximum benefit amountis $4,000, and will be reduced by any applicable deductible, copay, and/orcoinsurance.

20%* ADParticipating

Benefit Applies

INJECTABLE OR IMPLANTABLE MEDICATIONS YOU PAY

Injectable or Implantable Medications – Non-Facility –Injectable or implantable medications received in a physician’s office or through ahome health provider. (Preferred / Non-Preferred)

20%* / 30%* 40%* AD / 50%* AD

Injectable or Implantable Medications – Pharmacy(Preferred / Non-Preferred) 20%* / 30%*


PRESCRIPTION DRUGS YOU PAY

If you receive a brand name drug when a preferred generic equivalent can be substituted, you will pay the difference in cost between the genericand the brand name drug, any applicable deductible, and/or the generic copay. Regular benefits apply if a preferred generic cannot be substituted.

Prescription Drugs – Up to a 30-day supply. This benefit also includes thefollowing injectable medications when provided by an Altius participatingpharmacy: insulin, Imitrex, Symlin, Byetta, glucagon, Lovenox, and epinephrine kits(such as Epi-Pen).

Preferred Generic: $15Preferred Brand: $30Non-Preferred: $60


Prescription Drugs Mail Order – 90-day supply of maintenancemedication.

Preferred Generic: $30Preferred Brand: $60Non-Preferred: $120


MENTAL HEALTH / SUBSTANCE ABUSE YOU PAY

Inpatient Services 20%* AD 40%* AD

Partial Hospitalization 20%* AD 40%* AD

Services at an Outpatient Facility – Includes intensive outpatientservices. 20%* AD 40%* AD

Office Visits $40 40%* AD




3





ALLERGY CONDITIONS YOU PAY

Testing and Treatment $40 40%* AD

Serum 20%* AD 40%* AD

Injections You Pay Nothing 40%* AD

OTHER BENEFITS YOU PAY

Accident Related Dental Services – Dental services required as theresult of an accidental injury. Services include, but are not limited to, crowns, caps,bridges, and root canals. Limited to a combined lifetime maximum of $1,000 permember.

50% ADParticipating

Benefit Applies

Durable Medical Equipment (DME) – Including correctiveappliances and prosthetic devices. 50% 50%

Home Health Care – Limited to a combined benefit of 60 visits permember, per calendar year. 20%* AD 40%* AD

Hospice Care – Care for a terminally ill member through a licensed hospiceagency. 20%* AD 40%* AD

Implantable Contraceptives and Intra-Uterine Devices(IUDs) – Includes charges for insertion and removal. 20%* 40%* AD

Infertility Services – Evaluation, testing, and diagnostic services. Includesservices that are provided for the purpose of ruling out infertility. Limited to $750per member, per calendar year, up to a lifetime maximum of $5,000.

50% ADParticipating

Providers Only

Medical Supplies – Disposable medical supplies and accessories asdetermined medically necessary by Altius. 20% 50%

Neuropsychological Testing 50%* AD 50%* AD

Skilled Nursing Facility – Limited to a combined benefit of 60 days permember, per calendar year. 20%* AD 40%* AD

Sterilization Procedures – Services received at a physician’s office. $40 40%* AD

Sterilization Procedures – Services received at an outpatient facility. 20%* AD 40%* AD

Temporomandibular Joint Dysfunction (TMJ) – Evaluation,testing and diagnostic services. Limited to a combined lifetime maximum of $1,000. 50% AD 50% AD

GENERAL INFORMATION

Calendar Year Deductible – You must satisfy an individual or family deductible each calendar year before certain benefits will be providedunder this benefit plan. Deductibles do not apply to benefits with "fixed" copays and deductibles do not count towards the out-of-pocket maximum.

Out-of-Pocket Maximum – Fixed dollar copays and deductibles do not apply. When you or your family fulfill out-of-pocket maximums during acalendar year, then no further out-of-pocket expenses will be required for the remainder of that calendar year. This provision does not apply to any paymentsfor benefits with fixed copays, prescription drugs, dental services (even when necessitated by accidental injury), durable medical equipment, infertilityservices, TMJ services, charges that exceed eligible medical expenses, or non-covered services. You are required to keep receipts for out-of-pocket expensesand furnish such proof to the Altius Claims Department when you reach an out-of-pocket maximum.

Pre-Existing Condition Limitation – Coverage is excluded for the care and treatment of pre-existing conditions (excluding pregnancy),unless you have been continuously covered under a benefit plan with a health insurance carrier prior to your enrollment date with Altius Health Plans.Previous coverage may be used in satisfying all or part of the pre-existing condition waiting period requirement, except under the following circumstance:The previous health care coverage was terminated more than 63 days prior to your enrollment date of coverage with Altius Health Plans. Your enrollmentdate is your first day of coverage under your Altius plan or, if your employer has a pre-enrollment waiting period, the first day of the waiting period.

Securing Benefits and Payment for Services Through AltiusIn order for a medical service to be eligible for coverage, it must be defined as a covered benefit and properly coordinated through Altius. Priorauthorization is required for certain services (excluding emergency care) in order to verify that the services to be provided are covered by your benefit planand are medically necessary and appropriate. It is your responsibility to determine that providers and facilities have obtained prior authorization from Altiusprior to receiving care. If prior authorization from Altius is not obtained, coverage may be denied.


4PPCMPOS3102 Rev. 10-10

Limitations & Exclusions

When required by federal law, limitations and exclusions will not apply toinjuries resulting from an act of domestic violence or a medical condition(including both physical and mental health conditions).

The following benefits are limited under thisbenefit plan:

••• Physiotherapy services (occupational, physical and speech) arelimited to medically necessary services for conditions resulting fromillness or injury where therapy can be provided in a short-termrehabilitation program that is likely to significantly improve themember’s condition, as determined by Altius.

••• Altius reserves the right to include only one manufacturer’s producton the Altius formulary when the same or similar drug (that is, adrug with the same active ingredient), supply, or equipment is madeby two or more different manufacturers. The product or products notlisted on the Altius formulary will be excluded from coverage.

••• Altius reserves the right to include only one dosage or form of adrug on the Altius formulary when the same drug is available indifferent dosages or forms (for example, dissolvable tablets,capsules, etc.), from the same or different manufacturers. Theproduct or products in other forms or dosages that are not listed onthe Altius formulary will be excluded from coverage.

••• Implantable contraceptive capsules such as Norplant and Implanonare limited to one implantation and removal during the maximumimplantation period of the product, as determined by the productmanufacturer.

••• Neuropsychological evaluation and treatment is limited to thoseservices that diagnose or treat an underlying medical condition andis covered only when there is clinically significant braindysfunction.

••• Accident-related dental services are covered only when required as aresult of an accidental injury to sound, natural teeth. Dental servicesmust be received within two years following the accidental injury.

••• A determination by Altius that a service is infertility-related may bebased on medical records or other documented evidence, and is notdependent on whether Altius actually receives a claim with adiagnosis of infertility.

••• Certain medications, including those that are administered by amedical professional, are covered only when they are purchasedthrough designated specialty pharmacies. To obtain a current list ofthese medications, visit the Altius web site or call customer service.

••• Cochlear implants are covered only for those members who meet allof the following criteria: member has been diagnosed with bilateralprofound sensorineural hearing loss; member has a functioningauditory nerve; member is less than 18 years old; member has thecognitive ability to communicate effectively with restored hearing;hearing cannot be restored adequately with conventional hearingaids; and member and family are willing and able to participate inpost-implant rehabilitation.

The following are excluded from coverage underthis benefit plan:

••• Services provided outside the United States of America and itsterritories, except as required for an emergency or urgent condition.

••• New procedures, services, supplies, and medications until they arereviewed for safety, efficacy and cost effectiveness and approved byAltius.

••• Experimental or investigational treatment, procedures, tests,equipment, or facilities, or any health care service which is stillundergoing evaluation and review.

••• Services, drugs, and supplies that are not medically necessary, asdetermined by Altius.

••• Medication amounts in excess of maximum quantity and/or dosagelevels indicated by the drug manufacturer and the FDA.

••• Experimental medications; medications for non-approved FDAindications or non-approved indications determined by Altius HealthPlans; over-the-counter medications and products, except thosespecifically listed in the Altius formulary and those for whichcoverage is required by law; prescription medications that have an

over-the-counter equivalent or alternative, unless otherwisespecified in the Altius formulary; medications for athletic andmental performance; compounding fees; non-covered ingredientsused in a compounded medication; medications for cosmeticindications; hair growth products and medications; homeopathicmedications; hypodermic needles; impotence medications;medications for the treatment of infertility; skin patches for motionsickness; medications for the treatment of nail fungus; progesteronecream and suppositories; smoking cessation products, including anymedications prescribed for smoking cessation; medications requiredexclusively for foreign travel; oral vitamins (except prescriptionprenatal vitamins); medications for shift work sleep disorder;medications or nutritional supplements for weight loss, or for weightgain for non-medical conditions.

••• Replacement of lost, stolen, or damaged prescription drugs.••• Immunizations required exclusively for foreign travel.••• Food supplements, food substitutes, medical foods, and formulas

when taken orally, except when related to inborn errors of aminoacid or urea cycle metabolism.

••• Infertility treatment.••• In-vitro fertilization, GIFT, ZIFT, artificial insemination, and similar

services. This includes any related services such as prescriptionmedications, embryo transport, collection, and preparation costs.

••• Reversal of elective sterilization.••• Amniocentesis and ultrasonography for sex determination.••• Predictive genetic testing.••• Predictive diagnostic testing and screenings, and other preventive

services performed in the absence of illness or injury, other thanthose procedures or tests specifically recommended by Altius, theUnited States Preventive Services Task Force (USPSTF), theCenters for Disease Control (CDC), and local government publichealth authorities. Preventive services performed more often than, oroutside of the guidelines of Altius, the USPSTF, CDC, and localgovernment health authorities, are excluded.

••• Elective home delivery for childbirth.••• Procedures, services, drugs, and supplies related to elective

abortions, except when the life of the woman would be endangeredif the fetus were carried to term or when the pregnancy is the resultof an act of rape or incest, or to prevent the birth of a child thatwould be born with grave defects.

••• Surgical treatment for obesity (including morbid obesity) and/orcomplications therefrom, including a reversal of these surgeries.

••• Sex change operations or related health care services.••• Treatment, services, devices, and supplies related to sexual

dysfunction. This exclusion does not apply to implantation of apenile prosthesis or use of an external device for impotence causedby an organic disease such as diabetes mellitus or hypertension, orcaused by surgery for genitourinary cancer.

••• Surgery performed in order to prevent the possible onset of acondition or disease with which the member has not been diagnosed.

••• Services, supplies, or treatment in connection with cosmetic orreconstructive procedures which alter appearance but do not restoreor improve impaired physical function, or which are performed forpsychological or emotional purposes. This exclusion does not applyto: (1) reconstructive surgery required as the result of an accidentalinjury, infection, or cancer. Services must be rendered (or a planned,staged series of services, as specifically documented in themember’s medical record, must be initiated) within 12 months of thecause or onset of the injury, infection, or cancer; (2) circumcisionfor a newborn child up to three months of age; or (3) reconstructionof the breast(s) following a medically necessary mastectomy.

••• Treatment of hyperhidrosis (perspiration/sweating) or sialorrhea(drooling).

••• Autopsy procedures.••• Health education services not closely related to the care and

treatment of an illness or injury, except as specifically recommendedby the USPSTF and provided within USPSTF guidelines.

••• Services provided by an athletic trainer or a personal trainer.••• Telephone consultations, electronic mail communication, and

communication services that do not require direct face-to-facecontact between the patient and the provider.

••• Charges for failure to keep a scheduled appointment.


••• Interest or finance charges, except as specifically required by law.••• Prolotherapy (the use of injections to strengthen tendons and

ligaments).••• Services for crossmatching and/or harvesting organs when the organ

recipient is not an Altius member.••• Routine foot care. This exclusion does not apply to members with

severe diabetes.••• Treatment of weak, strained or imbalanced feet.••• Foot orthotics, wedges or shoe inserts, unless herein provided. This

exclusion does not apply to foot orthotics or shoe inserts formembers with severe diabetes.

••• Corrective appliances, prostheses, artificial aids and durable medicalequipment, including supplies and accessories, are excluded whendetermined to be primarily for convenience, comfort, non-therapeutic purposes, or in the absence of illness or injury.

••• Helmet therapy for benign positional plagiocephaly.••• Routine periodic servicing, such as cleaning and regulating, of

durable medical equipment, corrective appliances, and prostheses isnot covered. Replacement is not covered unless the existing devicehas become inoperable through normal wear and tear and cannot berepaired, or replacement is prescribed by a physician because of achange in the member’s physical condition.

••• All shipping, handling, or postage charges, except as incidentallyprovided without a separate charge.

••• Any devices used to aid hearing, including, but not limited to,cochlear implants for members 18 years of age and older andhearing aids, including the fitting of such devices and relatedhearing examinations.

••• Routine periodic servicing, repairs, batteries and accessories for anyhearing aid device.

••• Visual training and vision therapy.••• Eyeglasses, contact lenses, and examinations for contact lenses. This

exclusion does not apply to: (1) the first pair of contact lenses oreyeglasses following the initial diagnosis of aphakia or the surgicalremoval or surgical replacement of an organic lens; or (2)hydrophilic contact lenses used as a corneal bandage to treatconditions involving the cornea.

••• Eye surgeries performed primarily to correct refractive errors.Examples include, but are not limited to: PRK (photorefractivekeratectomy), LASIK (laser-assisted in-situ keratomileusis), RL(refractive lensectomy), ICRS (intracorneal ring segments), Intacs,phakic intraocular lenses (unless related to post-cataract surgery),and astigmatism correction (Limbal Relaxing Procedure). Thisexclusion does not apply to cornea transplants.

••• Non-emergency follow-up care provided in an emergency room.••• Charges for transportation, including ambulance, unless determined

medically necessary by Altius.••• Travel expenses, including hotel, motel and other non-medical room

and board.••• Private hospital rooms, unless medically necessary.••• Hospital take-home drugs and personal, comfort, or convenience

items.••• Private duty nursing.••• Custodial care, domiciliary care, rest cures, and independent living

training.••• Home health services requested for the convenience of the patient or

family that do not require the training and technical skills of a nurse.••• Hospice services that are not reasonable and necessary for palliation

or management of a terminal illness.••• Vocational testing and treatment.••• Physiotherapy services (occupational, physical and speech) for

psychosocial and/or developmental delays, including, but not limitedto speech therapy for stuttering.

••• Physiotherapy services (occupational, physical and speech) for workhardening or for recreational purposes, including, but not limited tosports or vocal performance.

••• Services related to the treatment of sensory processing dysfunctionor sensory integration disorder. This exclusion does not apply to theinitial assessment for diagnosis of the condition or to the medicalmanagement of an underlying medical illness which may becontributing to the condition.

••• Psychotherapy, counseling or other services in connection with maritalor family problems; social, occupational, religious, or other socialmaladjustments; conduct disorders; chronic adjustment disorders;psychosexual disorders; chronic organic brain syndromes; personalitydisorders; developmental disorders; learning disabilities; or mentalretardation. This exclusion does not apply to the initial assessment fordiagnosis of the condition, nor to the medical management of anunderlying medical illness which may be contributing to the disability.

••• Electrosleep or electronarcosis therapy, rapid detoxification programs,and milieu therapy.

••• Psychiatric treatments or services performed in the absence of apsychiatric diagnosis.

••• Treatment for mental disorders that are irreversible or for which thereis little or no reasonable expectation for improvement.

••• Substance abuse maintenance therapy, such as methadone clinicsand similar clinics and services.

••• Evaluation, testing, and treatment provided by public or privateschools.

••• Charges in connection with a work-related injury or sickness forwhich coverage is provided or would be provided under anyworkers’ compensation, employer’s liability, or occupational diseaselaw. When the employer is required by law to have such coverage,this exclusion applies whether or not such coverage is in effect.

••• Services, supplies, or treatment for which coverage is providedunder any motor vehicle no-fault plan. When the member is requiredby law to have no-fault insurance, this exclusion applies to chargesup to the minimum coverage required by law whether or not suchcoverage is in effect.

••• Expenses for which the member has no legal responsibility to pay orfor which the member would not ordinarily be charged in theabsence of coverage under this benefit plan.

••• Care for military service connected disability to which the memberis legally entitled, and for which facilities are reasonably available tothe member.

••• Care or treatment of an illness or injury caused by war or any act ofwar (whether declared or undeclared), hostilities, or activeparticipation in a riot or civil insurrection.

••• Care for conditions which state or local law requires to be treated ina public facility.

••• Services and treatments provided in connection with, or to complywith, involuntary admissions, police detentions, and similararrangements.

••• Examinations and services obtained for administrative purposes,such as treatment, care, reports or appearances obtained for, orpursuant to, legal proceedings, court orders, employment, continuingor obtaining insurance coverage, governmental licensure, travel, ormilitary services.

••• Oral surgery, including but not limited to orthognathic surgery, andany services related to the treatment of Temporomandibular JointSyndrome (TMJ), unless determined medically necessary by Altiusfor treatment of obstructive sleep apnea or direct treatment of aninvasive tumor or acute traumatic injury. This exclusion does notapply to diagnosis and evaluation of TMJ dysfunction.

••• Dental or orthodontic splints or dental prostheses, unless determinedmedically necessary by Altius for treatment of obstructive sleepapnea or necessitated by accidental injury.

••• Services related to the care, treatment, filling, removal, orreplacement of teeth or structures directly supporting the teeth,unless herein provided or necessitated by accidental injury.

••• Acupuncture or acupressure.••• Holistic and homeopathic treatments.••• Alternative medicine programs such as hypnosis, massage therapy

and biofeedback.••• Recreational therapy, wilderness therapy, or residential treatment

programs.••• Injury or illness sustained when in the act of an illegal activity.••• Services for which a provider waives the member’s copay,

coinsurance, and/or deductible.••• Services provided by a member of the patient’s immediate family or

household.


••• Expenses related to non-covered services, including pre- and post-operative evaluation, diagnostic testing, and complications resultingfrom non-covered services, supplies, and/or medications. When anon-covered procedure is performed as part of the same operation orprocess as a covered service, then only eligible charges relating tothe covered service will be covered.

••• Pre-existing conditions during the pre-existing condition waitingperiod, when applicable.

••• Benefits and services not specified as covered in the Group ServiceAgreement.

ALTIUS HEALTH PLANS10421 South Jordan Gateway Suite 400

South Jordan, UT 84095 • 800-365-1334www.AltiusHealthPlans.com

http://www.AltiusHealthPlans.com

Frequently Asked Questions:Q: Are there some procedures and services that are not

covered under the TransConnect plan?A: YES. Examples are mental and nervous conditions, alcoholism

or drug abuse claims, prescription drugs (unless prescribed while

an inpatient), and chemotherapy/radiation treatments received on an

outpatient basis.

Q: From which medical facilities may I receive treatment?A: You must receive treatment from a hospital (if an inpatient), the

outpatient facility of a hospital, a free-standing surgical center, or a MRI

facility. Surgical procedures in a physician’s office are not reimburs-

able. Clinics and urgent care facilities are not covered facilities under

the In-Hospital or Outpatient Hospital Benefit.

Here’s How Your Plan Works:These benefits help pay for the out-of-pocket expenses as a result of being an inpatient and expenses incurred due to surgeries,

emergency room treatment and ambulance transportation.

In-Hospital Claim Example:Hospital Stay and Surgery = $10,000 Total Expenses

with TransConnect without

$2,000 In-Hospital Benefit TransConnect

Deductible $1,000 $1,000

Co-Insurance $1,800 $1,800

Total Out-of-Pocket Expenses $2,800 $2,800

TransConnect Benefit $2,000 0

Net Out-of-Pocket** $800 $2,800

Outpatient Claim Example: Procedure: Arthroscopic Knee Surgery = $8,500 Total Expenses

with TransConnect without

$1,000 Outpatient Benefit TransConnect

Deductible $1,000 $1,000

Co-Insurance $1,500 $1,500

Total Out-of-Pocket $2,500 $2,500

TransConnect Benefit $1,000 0

Net Out-of-Pocket* $1,500 $2,500

**after the deductible, if any, has been satisfied.

Facts to Remember:1. A person must be covered by Another Medical Plan to be eligible for benefits under TransConnect.

2. Benefits are payable to the Insured. The Insured is responsible for filing his/her own claim with the Administrator and for paying the providers.

3. TransConnect may not cover 100% of the Insured’s out-of-pocket expenses.

4. Therapies such as physical and occupational therapy, radiation and chemotherapy are not covered unless received as an inpatient.

TransConnect® is underwritten by Transamerica Life Insurance Company,

Home Office: Cedar Rapids, IA. Administration is provided by Key Benefits Administrators, Inc.,

Customer Service: (866) 867-6883, Claims Fax: (866) 433-5152

ASL WSSHCS-0307

TransConnect® Plan Overview and BenefitsThese benefits help pay for Out-of-Pocket expenses as a result of being an inpatient and for expenses incurred due to surgeries, emergency

room treatment, and ambulance transportation.

In-Hospital BenefitThis benefit helps pay the out-of-pocket expense for:

4 Inpatient hospital stays.

4 Inpatient surgeries.

4 Physician’s in-hospital charges.

4 Routine nursery care for dependent children.

Outpatient Hospital BenefitThis benefit helps pay the out-of-pocket expense for:

4 Surgery in a hospital outpatient facility or a free-standing

outpatient surgery center.

4 Radiological diagnostic testing in a hospital outpatient facility

or MRI facility (this benefit does not cover lab fees).

4Treatment in a hospital emergency room for injury due to

an accident (emergency room charges for sickness are not

covered).

Ambulance Benefit - Accident OnlyThis benefit helps pay the out-of-pocket expenses incurred for ambu-

lance transportation (ground or air) to a hospital or emergency center

for injuries sustained in an accident. Transportation must be within 72

hours of the accident and provided by a licensed professional ambu-

lance company. This benefit is limited to $350 per calendar year per

covered person and a maximum of three times this amount per family.

Physician Office Outpatient Treatment Benefit (Optional)If selected by the employer, this benefit helps pay the out-of-pocket

expense for the following:

4 Treatment due to sickness.

4 Emergency care by a physician for an injury sustained in an

accident.

4 Routine well-child examinations and immunizations for

dependent children.

The covered person must not be an inpatient when charges are

incurred.

Transamerica CriticalAssistance Select

Plan Overview and Benefits

Critical Illness Benefit

After the waiting period, CriticalAssistance Select offers benefits to help with the costs associated with

critical illness when you or your insured loved ones are initially diagnosed with the following

conditions: cancer, heart attack, and stroke and end-stage renal failure. It even provides benefits for

major organ transplant surgery! This benefit is payable one time for each covered person.

Condition % of Critical Illness Benefit Amount

Cancer 100%

Heart Attack 100%

Stroke 100%

End-stage Renal Failure 100%

Major Organ Transplant Surgery 100%

Carcinoma In Situ* ** 5%

Skin Cancer* 5% *Payment for these benefits is one-time only, but will be paid in addition to any other benefit in this policy/certificate.

**Called Stage 0 Cancer in California.

Additional Benefits

Subsequent Critical Illness Benefit This benefit is payable if the covered person is first diagnosed as having a subsequent and separate

covered critical illness more than 60 days after the diagnosis of the first covered critical illness.

For Example: If you are first diagnosed with a heart attack, and then you are diagnosed for the first time

with a stroke more than 60 days later, you will receive the benefit amount you selected for each illness.

This benefit illness is payable one time for each covered person.

Critical Illness Screening Benefit This benefit pays $50 each year for each covered person for the following medical tests and procedures

performed at the direction of a license physician:

> chest X-Ray > colonoscopy > EKG

> mammography*** > Pap smear > stress echocardiograms

> flexible sigmoidoscopy > CA125 (test for ovarian cancer) > prostate-specific antigen test

> Hemoccult stool specimen > neuroimaging studies (PSA)

> thallium scan > MUGA scan > thermography

> blood tests to confirm elevated > carcinoembryonic antigen

cardiac enzymes test (CEA, test for colon

cancer)

***In California, the policy pays actual charges up to $100 per covered person, per calendar year.

Assurant Employee Benefits is the brand name used for insurance products underwrittenand issued by Union Security Insurance Company.

2436284/DEN/9/0 2010102811:32:43

Brigham City CorporationDental Insurance Benefit SummaryPresented by: Assurant Employee Benefits

Effective: January 1, 2011

EligibilityYou are eligible to participate if you are a full-time employee, as defined by your employer, at active work and working inthe United States. Other policyholder-defined eligibility requirements may apply. Temporary or seasonal workers are noteligible.

Plan DescriptionIn-Network Out-of-Network

Calendar Deductible – Individual $25 $50

Calendar Deductible – Family 3 individuals 3 individuals

Deductible Applies Class II & III Class I, II & III

Calendar Year Maximum Benefit $1,500 $1,500

Orthodontia Applies to Child Only

Orthodontia Deductible None None

Orthodontia Lifetime Maximum $2,000 $2,000

CoinsuranceIn-

Network*Out-of-Network

Highlights of Covered Services

Class I:Diagnostic &Preventive

100% 100%Oral evaluations, routine cleanings, bitewing X-rays, fluoride treatments, sealants,space maintainers, intraoral complete series X-rays or panoramic film, genetic testfor susceptibility to oral diseases.

Class II:Basic

90% 80%

Fillings, including tooth-colored fillings on posterior teeth, simple extractions,stainless steel crowns, root canal therapy, oral surgery, biopsy (including brushbiopsy), periodontics, localized delivery of antimicrobial agents, general anesthesiaand intravenous sedation, other X-rays.

Class III:Major

60% 50% Crowns, full and partial dentures, bridges, implants.

Class IV:Child OnlyOrthodontia

50% 50% Orthodontic extractions, full or partial bands, appliances (removable and fixed).

* Dental Health Alliance, L.L.C.®, (DHA®) – To locate a participating provider, or to nominate your current dental provider, visitwww.assurantemployeebenefits.com or call 800.985.9895. DHA is operated by Assurant Employee Benefits and owned by Union Security InsuranceCompany. DHA is Assurant Employee Benefits’dental PPO.

Pre-Estimation: If the charge for any dental treatment is expected to exceed $300, Assurant Employee Benefits recommends a dental treatmentplan be submitted to Claims for review before treatment begins.

Assurant Employee Benefits 8101 East Prentice Avenue, Suite 675

Greenwood Village, CO 80111 T 303.796.7990 800.445.0979 F 303.796.2769

Brigham City Corporation 10/29/2010 10:14:00 2436284/12/B

Premier Dental Solutions

Employees view dental coverage as a "real" benefit - one they know they need. And, because our approach to

dental coverage stresses prevention, this contract tends to be more affordable. Highlights of the Covered Services are shown below.

CLASS I: PREVENTIVE DENTAL SERVICES

Periodic or comprehensive oral evaluation Intraoral complete series X-rays or Panoramic film Bitewing X-rays

Routine cleanings Fluoride treatment Sealants

Space maintainers Genetic test for susceptibility to oral diseases

CLASS II: BASIC DENTAL SERVICES

NON-RESTORATIVE

Limited oral evaluation – problem focused Intraoral periapical or occlusal X-rays Periodontics (treatment of gums and supporting tissues)

Periodontal maintenance procedure Localized delivery of antimicrobial agents Endodontics, including root canal therapy

Oral surgery Accession and examination of tissue Stainless steel crowns Simple extractions

Biopsy (including brush biopsy) Incision and drainage General anesthesia and intravenous sedation

RESTORATIVE Amalgam restorations Composite restorations

Tooth-colored fillings on posterior teeth Pin retention restorations

CLASS III: MAJOR DENTAL SERVICES

Crowns, inlays, and onlays

Full and partial dentures Fixed bridges Implants

Tissue conditioning Denture adjustments Non-surgical temporomandibular joint (TMJ) treatment

Assurant Employee Benefits 8101 East Prentice Avenue, Suite 675

Greenwood Village, CO 80111 T 303.796.7990 800.445.0979 F 303.796.2769

Brigham City Corporation 10/29/2010 10:14:00 2436284/12/B

VISION DISCOUNT SERVICES

ACCESS PLAN

Your dental plan includes a vision discount plan through Vision Service Plan (VSP). The vision plan includes discounts on exams (including contact lens exams) and the purchase of eyeglasses, sunglasses and other prescription eyewear when provided by VSP doctors. VSP is available for you and everyone covered on your dental plan!

Services Available from a VSP Doctor Other Valuable Features for You

• Eye Exams – 20% discount applied to VSP doctor’s usual and customary fees for eye exams

1

• Glasses – 20% discount applied to VSP

doctor’s usual and customary fees for complete pairs of prescription glasses and spectacle lens options

2

• Contact Lenses – 15% discount off the contact lens exam (fitting and evaluation)

2.

• Laser VisionCareSM

– VSP has contracted with many of the nation's laser surgery facilities and doctors, offering you a discount off PRK and LASIK surgeries, available through contracted laser centers

• Immediate savings when using a VSP doctor

• You may use the discounts as often as you wish

• No waiting periods

• No deductibles

• No claim forms to fill out

How to Use VSP

Locate a VSP doctor near you. You may either use our Web-based doctor locator at www.vsp.com, or call VSP at 800.877.7195 to request a doctor listing.

Identify yourself as a VSP member and be prepared to provide the enrolled member’s social security number when you make your appointment. (The VSP doctor will verify your eligibility and vision plan coverage, and will obtain authorization for services and materials. If you are not currently eligible for services, the VSP doctor is responsible for communicating this to you.)

Your fees are automatically reduced at the time of service – with no claim forms to fill out!

THIS VISION DISCOUNT PLAN IS NOT INSURANCE.

1Note: Does not apply to contact lens services. See contact lens section for applicable discount.

2Discounts only offered through the VSP doctor who provided an eye exam within the last 12 months.

VSP Member Services Support: 800.877.7195 Visit our Web site at www.vsp.com

VSP

Brigham City Corporation is excited to offer the following

benefits package to their employees through The Hartford!

Your insurance plan consists of the following two types of coverages:

I. BASIC TERM LIFE:

Upon eligibility, you will have $50,000 of life insurance coverage

Matching amount of Accidental Death & Dismemberment benefit

Matching amount of Seat Belt benefit and additional AD&D benefits and enhancements

Guaranteed conversion privilege for employees

These benefits will reduce to 0 at age 65 and terminate upon retirement

Dependent Term Life:

$5,000 of coverage on your spouse

$2,000 of coverage on each of your dependent children

Complete the beneficiary form and return it to the Payroll Department where it is kept in your personal file.

II. SUPPLEMENTAL LIFE: Optional – For Employees Desiring Additional Low-Cost Term Coverage

You may apply for additional insurance, to supplement that described above, in increments of

$5,000 from a minimum of $20,000 to a maximum of $500,000. These benefits will reduce to 0 at

age 65 and terminate upon retirement

Your spouse may apply for up to 100% of your amount in increments of $5,000 from a minimum

of $10,000 to a maximum of $250,000. Supplemental spouse and dependent coverage is only

available provided you apply for an equal or greater amount of this supplemental coverage for

yourself. Spousal supplemental amount may not exceed employee’s supplemental amount

If you apply for a minimum of $20,000 on yourself, you may apply for $5,000 or $10,000

(maximum) of coverage for your children

Guaranteed conversion privilege for employees

Employee pays low monthly premium through payroll deduction

Refer to rate sheet included with this booklet for low supplemental life rates

Complete the supplemental application to apply for this additional coverage. If you only desire the basic coverage described

in Part I above, please disregard the supplemental application. Any supplemental coverages applied for that are subject to

underwriting will not be effective until the first of the month following date of underwriting approval. This letter is not a part of an insurance contract and merely summarizes selected information about insurance coverage. Please read the

complete insurance contract or certificate for a description of the benefits and terms of coverage. In the event of disagreement between the

information in this letter and your contract, the terms of the contract govern.

06/16/2003/100/CP

BRIGHAM CITY CORPORATION Group Supplemental Life Insurance Plan

Underwritten by Hartford Life and Accident Insurance Company

2007 Rates

Supplemental Life Insurance Monthly Rate Chart Worksheet

Supplemental Life Insurance for Employee and Spouse: Age Band: Non-Tobacco User Tobacco User

Under Age 30 $.05 $.0930 - 34 $.05 $.1135 - 39 $.06 $.1540 - 44 $.10 $.2445 - 49 $.17 $.3850 - 54 $.26 $.5755 - 59 $.37 $.7760 - 64 $.63 $1.2265 -69 $1.26 $2.2470 - 74 $2.64 $4.0075 - + $4.83 $6.77

Child Life Amount $5,000 $10,000

Monthly Cost per Unit $.60 $1.20

Upon calculating your elected Supplemental Life coverage amounts, please complete the Supplemental Life Insurance Enrollment Form. This worksheet does not serve as the enrollment form, and should be used only as a tool to estimate your coverage needs and premium calculations.

Premium CalculationUse the calculation line below to determine your cost for this coverage. Please be sure to indicate on the enrollment portion of your packet (page 3), the amount for which you are enrolling.

(Please be sure to indicate your Non-Tobacco/ Tobacco User status on page 3 of your enrollment form. If left blank, the rates will default to Tobacco User rates.)

÷ $1,000 = x = $Employee Elected

Benefit Amount Rate Above Your Monthly Cost

÷ $1,000 = x = $Spouse Elected Benefit Amount

Rate Above Your Monthly Cost

= $Child Life Amount

Your Monthly Cost equals Cost Per Unit above (rate includes coverage for all eligible children)

Check the Supplemental Life Benefit Highlights for a summary of the general benefits of the insurance described. Complete coverage information is in the certificate of insurance issued to you.

The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Policies sold in New York are underwritten by Hartford Life InsuranceCompany. Home Office of both companies: Simsbury, CT. All benefits are subject to the terms and conditions of the policy. Policies underwritten by the issuing companies listed above detail exclusions, limitations, reduction of benefits and terms under which the policies may be continued in force or discontinued.

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,egap gniwollof eht no debircsed sA .seY ecnarusnI ytilibasiD mreT trohS diaP reyolpmE tfieneb .eviecer uoy emocni rehto yb decuder eb yam

eht nac ,delbasid m’I fI eb tfieneb ym fo tnuoma

?decuder

ecnarusnI ytilibasiD mreT trohS diaP reyolpmE

.lauqe tuohtiw esitrepxE .nedrub tuohtiw stfieneB MS

0-30302 egaP 3 fo 4

Underwritten by Hartford Life and Accident Insurance Company. The Hartford® is The Hartford Financial Services Group, Inc. and its subsidiaries, including issuing companies Hartford Life Insurance Company and Hartford Life and Accident Insurance Company. Policies sold in New York are underwritten by Hartford Life Insurance Company. Home Off ce of both companies: Simsbury, CT. All benef tsii are subject to the terms and conditions of the policy. Policies underwritten by the issuing companies listed above detail exclusions, limitations, reduction of benef ts and terms under which the policies mayi be continued in force or discontinued.

Brigham City Corporation Non Contrib

Rev 03/08

sliateD tnatropmI

ruoy fo weivrevo na si gniwollof ehT ecnarusnI ytilibasiD mreT trohS diaP reyolpmE a ,reyolpme ruoy ot deussi si ycilop puorg a ecnO . .liated ni egarevoc ruoy nialpxe ot elbaliava eb lliw ecnarusnI fo etacfiitrec

:snoisulcxE

eviecer tonnac uoY ecnarusnI ytilibasiD mreT trohS diaP reyolpmE :yb ot detubirtnoc ro desuac era taht seitilibasid rof stnemyap tfieneb • )ton ro deralced( raw fo tca ro raW • ynolef a timmoc ot tpmetta ro ,fo noissimmoc ehT • yrujni detcilfni-fles yllanoitnetni nA • ytilibasid ruoy ot esuac gnitubirtnoc a saw noitapucco lagelli na ni degagne gnieb ruoy erehw esac ynA • demialc ylud fi ,diap eb yam ro ,diap era stifeneb noitasnepmoC 'srekroW hcihw rof yrujni ro ssenkciS • reyolpme rehtona rof tiforp ro yap rof krow yna gniod fo tluser a sa deniatsus yrujni ynA

.stfieneb eviecer ot naicisyhp a fo erac raluger eht rednu eb tsum uoY stnemyap tifeneb ruoY decuder eb lliw :sa hcus ,ytilibasid ruoy ot eud eviecer ot elbigile era ro eviecer uoy emocni rehto yb

• )snoitpecxe rof noitces txen ees esaelp( ecnarusnI ytilibasiD ytiruceS laicoS • noitasnepmoC 'srekroW • evah yam uoy egarevoc ecnarusnI desab-reyolpme rehtO • stifeneb tnemyolpmenU • ssol emocni rof stnemgduj ro stnemeltteS • )nalp noisnep a sa hcus( rof syap yllaitrap ro ylluf reyolpme ruoy taht stifeneb tnemeriteR

stnemyap tifeneb ruoY decuder eb ton lliw :sa hcus ,emocni rehto fo sdnik niatrec yb • delbasid emaceb uoy erofeb meht gniviecer ydaerla erew uoy fi stifeneb tnemeriteR • snoitubirtnoc xat-retfa ruoy yb dednuf era taht eviecer ot trats uoy stifeneb tnemeriteR • shgoeK ro sARI ,stnemtsevni ,sgnivas lanosrep ruoY • gnirahs-tiforP • seicilop ytilibasid lanosreP • sesaercni ytiruceS laicoS

eht fo weivrevo na si teehS sthgilhgiH tfieneB sihT ecnarusnI ytilibasiD mreT trohS diaP reyolpmE -li rof dedivorp si dna dereffo gnieb -si ycilop ecnarusnI eht ylnO .deussi yllautca sa ycilop eht stceffa ro segnahc yaw on ni tI .tcartnoc a ton si dna ylno sesoprup evitartsul

ruoy fo snoisulcxe dna snoitatimil ,snoitidnoc ,smret ,snoisivorp eht fo lla ebircsed ylluf nac )reyolpme ruoy( redlohycilop eht ot deus -usnI eht fo smret eht ,ycilop ecnarusnI eht dna teehS sthgilhgiH tfieneB eht neewteb ecnereffid yna fo tneve eht nI .egarevoc ecnarusnI

.ylppa ycilop ecnar

0-30302 egaP 4 fo 4



Rev 03/08

sthgilhgiH tifeneB

noitaroproC ytiC mahgirB

ecnarusnI ytilibasiD mreT gnoL diaP reyolpmE ruoy fo noitrop a uoy syap sgninraE uoy fi .yrujni ro ssenlli gnilbasid a fo esuaceb krow tonnac

ruoy fo weivrevo na si teehs thgilhgih sihT ecnarusnI ytilibasiD mreT gnoL diaP reyolpmE .

ot elbaliava eb lliw ecnarusnI fo etacfiitrec a ,reyolpme ruoy ot deussi si ycilop puorg a ecnO .liated ni egarevoc ruoy nialpxe

si tahW gnoL diaP reyolpmE ecnarusnI ytilibasiD mreT ?

.reyolpme ruoy htiw tcartnoc s’droftraH ehT ni denfied si ytilibasiD snaem ytilibasid ,yllacipyT ,yrujni ot eud noitapucco ruoy fo seitud laitnesse eht fo erom ro eno mrofrep tonnac uoy taht

ruoy ,tluser a sa dna ,ecnarusni eht yb derevoc noitidnoc lacidem rehto ro ycnangerp ,ssenkcis evah uoy ecnO .sgninrae ytilibasid-erp ruoy fo naht ssel ro %08 era sgninrae ylhtnom tnerruc

eht fo erom ro eno gnimrofrep morf detneverp eb tsum uoy ,shtnom 42 rof delbasid neeb ro %06 era sgninrae ylhtnom tnerruc ruoy ,tluser a sa dna noitapucco yna fo seitud laitnesse

sgninrae ytilibasid-erp ruoy fo naht ssel .

?ytilibasid si tahW

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?elbigile I mA

taht egarevoc sedivorP reyolpmE ruoY fo tfieneb a uoy syap %76.66 ruoy fo sgninraE a ot fo tfieneb ylhtnom mumixam 000,8$ .htnom rep fo tfieneb muminim a sedulcni nalp sihT eht

:fo retaerg %01 rehtO fo noitcuded eht erofeb ssoL emocnI ylhtnoM no desab tfieneb eht fo stfieneB emocnI ro 001$ htnom rep .

sgninraE era .reyolpme ruoy htiw tcartnoc s’droftraH ehT ni sa denfied

egarevoc hcum woH ?evah I dluow

elbigile na sA eeyolpmE yb derevoc yllacitamotua era uoy , ytilibasiD mreT gnoL diaP reyolpmE ecnarusnI .llorne ot evah ton od uoy ;

?llorne I nac nehW

lliw esac on nI .ycilop eht fo snoitidnoc dna smret eht ot tcejbus tceffe otni seog egarevoC naht renoos evitceffe emoceb stfieneb detcele ylwen 0102/1/6 ro erih fo etad eht no tsum uoY .

.tceffe sekat egarevoc ruoy yad eht no reyolpme ruoy htiw kroW ta ylevitcA eb

?evitceffe ti si nehW

tsael ta rof delbasid eb tsum uoY syad 09 na eviecer nac uoy erofeb mreT gnoL diaP reyolpmE ecnarusnI ytilibasiD .tnemyap tfieneb

tiaw ot evah I od gnol woH ym eviecer nac I erofeb ?tfieneb

ecnarusnI ytilibasiD mreT gnoL diaP reyolpmE

.lauqe tuohtiw esitrepxE .nedrub tuohtiw stfieneB MS

0-30302 egaP 1 fo 4



Rev 03/08

ehT ni defiiceps sa sega niatrec hcaer uoy ecno decuder eb yam noitarud tfieneb ruoY .seY tnatropmI eht nihtiw woleb debircsed sa ,noitidda nI .reyolpme ruoy htiw tcartnoc s'droftraH

.eviecer uoy emocni rehto yb decuder eb yam tfieneb mreT-gnoL ylhtnom ruoy ,sliateD

tnuoma ro noitarud eht naC ?decuder eb tfieneb ym fo

tnemeriteR lamroN ytiruceS laicoS ruoy hcaer uoy litnu ro ,delbasid niamer uoy sa gnol sa roF si revehcihw ,)tcA ytiruceS laicoS setatS detinU eht fo noisiver 3891 eht ni detats sa( egA

.decuder eb yam stnemyap ruoy ,evoba ro 56 ega ta srucco ytilibasid ruoy fI .renoos

ytilibasid ym lliw gnol woH ?eunitnoc stnemyap

sliateD tnatropmI

ruoy fo weivrevo na si gniwollof ehT ecnarusnI ytilibasiD mreT gnoL diaP reyolpmE a ,reyolpme ruoy ot deussi si ycilop puorg a ecnO . .liated ni egarevoc ruoy nialpxe ot elbaliava eb lliw ecnarusnI fo etacfiitrec

:snoisulcxE eviecer tonnac uoY ecnarusnI ytilibasiD mreT gnoL diaP reyolpmE :yb ot detubirtnoc ro desuac era taht seitilibasid rof stnemyap tfieneb

• )ton ro deralced( raw fo tca ro raW • ynolef a timmoc ot tpmetta ro ,fo noissimmoc ehT • yrujni detciflni-fles yllanoitnetni nA • ytilibasid ruoy ot esuac gnitubirtnoc a saw noitapucco lagelli na ni degagne gnieb ruoy erehw esac ynA

.stfieneb eviecer ot naicisyhp a fo erac raluger eht rednu eb tsum uoY

:snoitidnoC gnitsixe-erP a rof erac deviecer ro desongaid erew uoy fi ,lareneg nI .snoitidnoc gnitsixe-erp rof eviecer nac uoy stfieneb eht stimil ecnarusnI ruoY

:fi ylno noitidnoc taht ot eud ytilibasid a rof derevoc eb lliw uoy ,ecnarusnI ruoy fo etad evitceffe eht erofeb noitidnoc • ruoy fo etad evitceffe eht erofeb tcartnoc eht ni defiiceps emit fo htgnel eht rof noitidnoc ruoy rof tnemtaert deviecer ton evah uoY

ro ,ecnarusnI • -er nac uoy os ,strats ytilibasid ruoy erofeb tcartnoc eht ni defiiceps emit fo htgnel rof ecnarusnI siht rednu derusni neeb evah uoY

ro ,tnemtaert gniviecer er'uoy fi neve stfieneb eviec • .rerusni suoiverp ruoy fo tnemeriuqer noitidnoc gnitsixe-erp eht defisitas ydaerla evah uoY

eht fo weivrevo na si teehS sthgilhgiH tfieneB sihT ecnarusnI ytilibasiD mreT gnoL diaP reyolpmE rof dedivorp si dna dereffo gnieb ycilop ecnarusnI eht ylnO .deussi yllautca sa ycilop eht stceffa ro segnahc yaw on ni tI .tcartnoc a ton si dna ylno sesoprup evitartsulli ruoy fo snoisulcxe dna snoitatimil ,snoitidnoc ,smret ,snoisivorp eht fo lla ebircsed ylluf nac )reyolpme ruoy( redlohycilop eht ot deussi

eht fo smret eht ,ycilop ecnarusnI eht dna teehS sthgilhgiH tfieneB eht neewteb ecnereffid yna fo tneve eht nI .egarevoc ecnarusnI .ylppa ycilop ecnarusnI

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.emitefil ruoy gnirud sdoirep ytilibasid lla rof shtnom 42 fo latot • msilohocla ,ssenlli latnem rof erac lacidem edivorp ot desnecil ytilicaf rehto ro latipsoh a ni denfinoc era uoy taht emit fo doirep ynA

.timil emitefil shtnom 42 eht drawot tnuoc ton seod esuba ecnatsbus dna

stnemyap tfieneb ruoY decuder eb lliw :sa hcus ,ytilibasid ruoy ot eud eviecer ot elbigile era ro eviecer uoy emocni rehto yb • )snoitpecxe rof noitces txen ees esaelp( ecnarusnI ytilibasiD ytiruceS laicoS • noitasnepmoC 'srekroW • evah yam uoy egarevoc ecnarusnI desab-reyolpme rehtO • stfieneb tnemyolpmenU • ssol emocni rof stnemgduj ro stnemeltteS • )nalp noisnep a sa hcus( rof syap yllaitrap ro ylluf reyolpme ruoy taht stfieneb tnemeriteR

stnemyap tfieneb ruoY decuder eb ton lliw :sa hcus ,emocni rehto fo sdnik niatrec yb • delbasid emaceb uoy erofeb meht gniviecer ydaerla erew uoy fi stfieneb tnemeriteR • snoitubirtnoc xat-retfa ruoy yb dednuf era taht stfieneb tnemeriteR • shgoeK ro sARI ,stnemtsevni ,sgnivas lanosrep ruoY • gnirahs-tfiorP • seicilop ytilibasid lanosrep tsoM • sesaercni ytiruceS laicoS

0-30302 egaP 2 fo 4



Rev 03/08

Your Section 125 Cafeteria Plan

A plan that enhances your benefits If you: 1) have premium deducted from your paycheck for

medical, dental, or vision coverage, 2) incur out-of-pocket

medical costs, or 3) spend money on the care of

dependents, a Section 125 Cafeteria Plan, created by the

United States Congress under IRS Code Section 125, can

make these expenses more affordable for you.

How it works

If you participate, you may elect to have a specified

amount of pretaxed money deducted from your paycheck

each pay period for: 1) Premiums - to pay the for

qualified insurance coverages, 2) Health Care Spending

Account - to be reimbursed for certain out-of-pocket

medical, dental, vision and/or hearing expenses, and 3)

Dependent Care Spending Account - to be reimbursed

for child care payments made to someone other than a

dependent of the employee. The dollars elected for the

Health Care and Dependent Care Spending Accounts are

set aside in a flexible spending account. When you submit

a receipt for qualified expenses, you will be reimbursed

from this account. These pretax dollars are subtracted

from your gross earnings before taxes are taken out. Thus,

when you pay for qualified expenses before tax, you lower

your taxable income and increase your take home pay.

With your Section 125 Cafeteria Plan: Your benefits are more affordable.

Your spendable income increases

You pay less in taxes

Once enrolled, can I make a change? To comply with IRS requirements, you may make a

change in your election only at the beginning of each plan

year. The latest set of cafeteria plan regulations outlines a

process for determining if a participant is allowed to make

a change in election during the plan year. The two step

process is:

1. A change in status must have occurred. A

change in status has occurred if the event falls into

one of the categories below:

Legal marital status

Number of dependents

Employment status

Dependent satisfies (or ceases to satisfy)

eligibility requirements

Change of residence

2. The participant’s election change must be

consistent with the status change event. In order

to be consistent, a requested change must be on

account of and correspond with a change in status

that affects eligibility for coverage under an

employer-sponsored plan.

Example: Assume a gross monthly salary of $2,000,

premium contribution of $160, dependent care of $200,

and out-of-pocket expense of $60, for a total of $420.

Without 125 Plan

With 125 Plan

Gross Pay $2,000 $2,000

Amount withheld for Section

125

-0-

$420

Taxable Earnings

minus:

$2,000 $1,580

Federal Income tax (15%) $300 $237

State Income tax (7.2%) $144 $114

FICA (7.65%) $153 $121

Same expenses paid after

taxes….

$420 -0-

Take Home Pay $983 $1108

monthly savings $125

annual savings $1500

What if the tax laws change? Tax advantages currently available are based on the law as

it stands today. If a change in the law takes place, you

will be notified.

Will pre-taxing have an impact on Social

Security benefits? The Social Security benefit is based on total wages

accumulated during your lifetime, and the government has

a formula it uses to calculate these benefits that is always

subject to change. Any reduction in your taxable pay may

also lead to a reduction in your Social Security benefits;

however, for most employees, the reduction in Social

Security benefits is insignificant compared to the value of

paying lower taxes today.

Free-Look Provision

According to state regulations, you have a certain number

of days after receiving your policy to cancel your policy.

This is known as the free-look provision and is 10 days in

Utah. It’s important to know this because if you cancel

your coverage after the effective date of the flexible

benefits plan, the IRS may not allow your employer to

stop payroll deductions. All requests for cancellation of

coverage must be made to your employer.

Administered by

HHeeaalltthh CCaarree SSppeennddiinngg

AAccccoouunntt IInnffoorrmmaattiioonn How much can I contribute? Brigham City Corp. has set this maximum allowable

contribution for health care flexible spending account:

$10,000 per employee

Eligible expenses A health care FSA may be used to pay health care

expenses not covered under any other plan.

Qualified expenses include:

Deductibles and other Payments you must make

under your medical plan.

Charges that may not be covered by your medical

plan, such as:

Dependent physicals Hearing aids

Well-baby care Dental care

Eyeglasses/Contact lenses Braces

Birth Control pills Routine Exams

Miscellaneous expenses, such as:

Individual psychiatric or psychological

counseling.

Special education for the blind (such as a

typewriter).

Special instructions or training for the deaf

(such as lip reading).

Costs of acquiring and training a dog for the

deaf or blind.

Public transportation to receive medical care

(must provide receipt).

Other healthcare services that qualify as medical

deductions under IRS rules:

Special medical equipment.

Qualified medical products or services

prescribed by a doctor for which you must

pay out-of-pocket.

Please refer to Section 213(d) of the Internal Revenue Code for

the IRS definition of deductible medical expenses that are

eligible for reimbursement.

Note: An expense is not eligible if it is for cosmetic reasons

only. Also, premiums for health coverage are not eligible for

reimbursement.

How much should I contribute? Now that you have a better idea what qualifies, try to

determine how much you might spend on these types of

expense during the next plan year. To be safe, be

conservative in your estimates. Start with predictable

known expenses such as contact lenses and prescription

medications. Remember, the expenses you choose cannot

be covered by any other medical plan.

DDeeppeennddeenntt CCaarree SSppeennddiinngg

AAccccoouunntt IInnffoorrmmaattiioonn

How much can I contribute? The U.S. Congress has set these maximum allowable

contributions for a dependent care flexible spending account:

$5,000 for a married couple filing jointly.

$5,000 for a single parent.

$2,500 for a married person filing separately.

Eligible expenses You may use the plan for expenses that meet the following

qualifications:

The dependent care must enable you and your spouse

to be employed.

The amount to be reimbursed must not be greater than

your spouse’s income or one-half of your income,

whichever is less.

The child must be under 13 years old and must be

your dependent under federal tax rules. Note: If your

child turns 13 during the plan year, reimbursements

must stop. Your contributions, however, must

continue throughout the year, so plan carefully.

The services may be provided in your home or another

location but not by someone who is your minor child

or dependent for income tax purposes (for example, an

older child).

If the services are provided by a day care facility that

cares for six or more children at the same time, the

facility must comply with state and local day care

regulations.

Services must be for the physical care of the child, not

for education, meals, etc.

Qualified dependent care expenses also include costs for

the care of a spouse or dependent who is incapable of

self-care and regularly spends at least eight hours per

day in your home (i.e. an invalid parent). The same rules

that apply for child care apply to the care of other

dependents, except that the dependent need not be under

age 13.

The “Use it or lose it” rule: If you contribute dollars to a reimbursement account

and do not use all of the monies you deposit, you will

lose any remaining balance in the account at the end of

the plan year.

A very important rule to remember…the rule exists

because the IRS has established strict guidelines on

plans with tax advantages. So estimate carefully the

amount you want to contribute to your health care or

dependent care FSA, and only contribute dollars

you’re confident will be used before the end of the plan

year.

MODEL GENERAL NOTICE OF COBRA CONTINUATION COVERAGE RIGHTS

**CONTINUATION COVERAGE RIGHTS UNDER COBRA**

Introduction

You are receiving this notice because you have recently become covered under a group health

plan (the plan). This notice contains important information about your right to COBRA

continuation coverage, with is a temporary extension of coverage under the Plan. This notice

generally explains COBRA continuation coverage, when it may become available to you and

your family, and what you need to do to protect the right to receive it.

The right to COBRA continuation coverage was created by a federal law, the Consolidated

Omnibus Budget Reconciliation Act of 1985 (COBRA). COBRA continuation coverage can

become available to you when you would otherwise lose your group health coverage. It can also

become available to other members of you family who are covered under the Plan when they

would otherwise lose their group health coverage. For additional information about your rights

and obligations under the Plan and under federal law, you should review the Plan‟s Summary

Plan Description or contact the Plan Administrator.

What is COBRA Continuation Coverage?

COBRA continuation coverage is a continuation of Plan coverage when coverage would

otherwise end because of a life event known as a “qualifying event.” Specific qualifying events

are listed later in this notice. After a qualifying event COBRA continuation coverage must be

offered to each person who is a “qualified beneficiary.” You, your spouse, and your dependent

children could become qualified beneficiaries if coverage under the Plan is lost because of the

qualifying event. Under the Plan, qualified beneficiaries who elect COBRA continuation

coverage must pay for COBRA continuation coverage.

If you a re an employee, you will become a qualified beneficiary if you lose your coverage under

the Plan because either one of the following qualifying events happens:

Your hours of employment are reducer, or

Your employment ends for any reason other than your gross misconduct.

If you are the spouse of an employee, you will become a qualified beneficiary if you lose your

coverage under the Plan because any of the following qualifying events happens:

Your spouse dies;

Your spouse‟s hours of employment are reduced;

Your spouse‟s employment ends for any reason other that his or her gross misconduct;

Your spouse becomes entitled to Medicare benefits (under Part A, Part B, or both); or

You become divorced or legally separated from your spouse.

Your dependent children will become qualified beneficiaries if they lose coverage under the Plan

because any of the following qualifying events happens:

The parent-employee dies;

The parent-employee‟s hours of employment are reduced;

The parent-employee‟s employment ends for any reason other than his or her gross

misconduct;

The parent-employee becomes entitled to Medicare benefits )Part A, Part B, or both);

The parents become divorced or legally separated; or

The child stops being eligible for coverage under the plan as a “dependent child.”

When is COBRA Coverage Available?

The Plan will offer COBRA continuation coverage to qualified beneficiaries only after the Plan

Administrator has been notified that a qualifying event has occurred. When the qualifying event

is the end of employment or reduction of hours of employment, death of the employee, or the

employee‟s becoming entitled to Medicare benefits (under Part A, Part B or both), the employer

must notify the Plan Administrator of the qualifying event.

You Must Give Notice of Some Qualifying Events

For the other qualifying events (divorce or legal separation of the employee and spouse or a

dependent child’s losing eligibility for coverage as a dependent child), you must notify the

Plan Administrator within 60 days.

You must provide this notice to:

Brigham City Corporation

Attn: Plan Administrator

20 North Main

Brigham City, UT 84302

How is COBRA Coverage Provided?

Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA

continuation coverage will be offered to each of the qualifying beneficiaries. Each qualified

beneficiary will have an independent right too elect COBRA continuation coverage. Covered

employees may elect COBRA continuation coverage on behalf of their spouses, and parents may

elect COBRA continuation coverage on behalf of their children.

COBRA continuation coverage is a temporary continuation of coverage. When the qualifying

event is the death of the employee, the employee‟s becoming entitled to Medicare benefits (under

Part A, Part B, or both), your divorce or legal separation, or a dependent child‟s losing eligibility

as a dependent child, COBRA continuation coverage lasts for up to a total of 36 months. When

the qualifying event is the end of employment or reduction of the employee‟s hours of

employment, and the employee became entitled to Medicare benefits less than 18 months before

the qualifying event, COBRA continuation coverage for qualified beneficiaries other than the

employee lasts until 36 months after the date of Medicare entitlement. For example, if a covered

employee becomes entitled to Medicare 8 months before the date on which his employment

terminates, COBRA continuation coverage for his spouse and children can last up to 36 months

after the date of Medicare entitlement, which is equal to 28 months after the date of the qualifying

event (36 months minus 8 months). Otherwise, when the qualifying event is the end of

employment or reduction of the employee‟s hours of employment, COBRA continuation

coverage generally lasts for only up to a total of 18 months. There are two ways in which this 18-

month period of COBRA continuation coverage can be extended.

Disability extension of 18-month period of continuation coverage

If you or anyone in your family covered under the Plan is determined by the Social Security

Administration to be disabled and you notify the Plan administrator in a timely fashion, you and

your entire family may be entitled to receive up to an additional 11 months of COBRA

continuation coverage, for a total maximum of 29 months. The disability would have started at

some time before the 60th day of the COBRA continuation coverage and must last at least until

the end of the 18-month period of continuation coverage

Second qualifying event extension of 18-month period of continuation coverage

If your family experiences another qualifying event while receiving 18 months of COBRA

continuation coverage, the spouse and dependent children in your family can get up to 18

additional months of COBRA continuation coverage, for a maximum of 36 months, if notice of

the second qualifying event is properly given to the Plan. This extension may be available to the

spouse and any dependent children receiving continuation coverage if the employee or former

employee dies, becomes entitled to Medicare benefits (under Part A, Part B, or both), or gets

divorced or legally separated, or if the dependent child stops being eligible under the Plan as a

dependent child, but only if the event would have caused the spouse or dependent child to lose

coverage under the Plan had the first qualifying event not occurred.

If You Have Questions

Questions concerning your Plan or your COBRA continuation coverage rights should be

addressed to the contact or contacts identified below. For more information about your rights

under ERISA, including COBRA, the Health Insurance Portability and Accountability Act

(HIPAA), and other laws affecting group health plans, contact the nearest Region or District

Office of the U.S. Department of Labor‟s Employee Benefits Security Administration (EBSA) in

your area or visit the EBSA website at WWW.dol.gov/ebsa. (Address and phone numbers of

Regional and District EBSA Offices are available through EBSA‟s website.)

Keep Your Plan Informed of Address Changes

In order to protect your family‟s rights, you should keep the Plan Administrator informed of any

changes in the address of family members. You should also keep a copy, for your records, of any

notices you send to the Plan Administrator.

Plan Contact Information


Attn: Plan Administrator

20 North Main


435-734-6630

http://www.dol.gov/ebsa

NOTIFICATION TO EMPLOYER OF QUALIFYING EVENT Under the Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) the employee or a

family member is responsible for informing the employer or Plan Administrator of a divorce, legal

separation, or a child losing dependent status under the employer's Health Plan. This notification

must be provided to the employer within 60 days from the later of the qualifying event date or the

date coverage would be lost due to the event.

FAILURE TO NOTIFY THE EMPLOYER OF ONE OF THESE EVENTS WITHIN 60

DAYS MAY RESULT IN THE LOSS OF YOUR CONTINUATION COVERAGE RIGHTS. Under the Omnibus Budget Reconciliation Act of 1989 (OBRA), if loss of coverage results from a

covered employee‟s termination or reduction in hours, a qualified beneficiary is allowed to extend

their COBRA coverage from 18 to 29 months if the qualified beneficiary is deemed to have been

disabled at the time of the termination or reduction of hours or within 60 days after that date. To

receive this additional coverage, you must provide the Employer or Plan Administrator with the

Notice of Determination of disability from the social Security Administration before the expiration

of the initial 18 month period and with 60 days of the determination.

Employer's Name: _____Brigham City Corporation___________________________

Employee's Name: ________________________________

Please complete the following information on the qualified beneficiary.

NAME______________________________________________SOCIAL SEC #__________________

ADDRESS___________________________________________________________________________

CITY_________________________________STATE___________________ZIP__________________

Please indicate qualifying event and the date

( )Dependent Ceasing to be a Dependent Date: ___/___/___

( )Divorce/Legal Separation Date: ___/___/___

( )Disabled as of Date of Termination Date: ___/___/___

or Reduction of Hours (Attach Determination

of Disability from the Social Security Administration)

or within 60 days thereafter.

______________________________________ __________________________

Signature Date

Please return this form to your employer upon completion.

NOTIFICATION TO EMPLOYER OF CHANGE OF ADDRESS

FOR EMPLOYEE

To: _________Brigham City Corporation________ Date: ________________________

From: _____________________________ SSN ________________________

Please make the following change of address:

Street: _________________________

City: __________________________

State: _____________ Zip: ________

Phone: ________________________

Please make this change effective: __________________________

Thank you,

_________________________________

Signature

NEW HIRE STATEMENT OF RIGHTS HEALTH INSURANCE PORTABILITY

AND ACCOUNTABILITY ACT OF 1996 (HIPAA)

1. Right to Request a Certificate of Coverage

Recent changes in Federal law may affect your health coverage if you are enrolled or become

eligible to enroll in health coverage that excludes coverage for pre-existing medical conditions.

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) limits the

circumstances under which coverage may be excluded for medical conditions present before you

enroll for coverage. Under the law, a pre-existing condition exclusion generally may not be

imposed for more than 12 months (or 18 months for late enrollees). The 12-month (or 18-month)

exclusion period is reduced by your prior health coverage. You are entitled to a certificate that

will provide evidence of your prior health coverage. If you buy health insurance other than

through an employer group health plan, a certificate of prior coverage may help you obtain

coverage without a pre-existing condition exclusion. You may contact your State Insurance

Department for further information.

For employer group health plans, these changes generally take effect at the beginning of the first

plan year starting after June 30, 1997. For example, if your employer‟s plan year begins on

January 1, 1998, the plan is not required to give you credit for your prior coverage until January

1, 1998.

You have the right to receive a certificate of prior health coverage since July 1, 1996. You may

need to provide other documentation for earlier periods of health care coverage. Check with your

new plan administrator to see if your new plan excludes coverage for pre-existing conditions and

if you need to provide a certificate or other documentation of your previous coverage.

To get a certificate, complete the form below and return it to:

Derek Oyler


20 North Main


For Additional Information Contact: 435-734-6630

The certificate must be provided to you promptly. Keep a copy of this completed form. You may

also request certificates for any of your dependents (including your spouse) who were enrolled

under your health coverage.

REQUEST FOR CERTIFICATE OF HEALTH COVERAGE

Name of Participant: _____________________________________________________________

Address: ______________________________________________________________________

Telephone Number:____________________________ Date: _____________________________

Name and relationship of any dependents for whom certificates are requested (and their address if

different from above):

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

______________________________________________________________________________

2. Portability of Health Coverage

HIPAA enables individuals to obtain coverage more readily when changing jobs

and moving from one group health plan to another. Under HIPAA, covered

persons may receive credit for prior creditable coverage under a qualified group

plan as long as coverage has not lapsed longer than 63 days. You may have a

lapse in coverage for up to 62 days without losing your prior creditable coverage.

A waiting period or affiliation period for an HMO is not considered a break in

coverage.

Creditable coverage includes any group plan or policy, certain individual

coverage‟s, Medicare, Medicaid, military services-related care, Indian Health

Service Plan or State High Risk Pool.

Creditable coverage may assist you in gaining uninterrupted future coverage

without a pre-existing condition waiting period. Group health plans may refuse

or limit coverage on a new enrollee for up to 12 months, or 18 months for late

entrants, for a health condition that was diagnosed or treated within the six month

period prior to enrollment.

The period of any pre-existing condition exclusion that would otherwise apply to

an individual under a group health plan is reduced by the number of days of

creditable coverage the individual has as of the enrollment date.

Effective with renewal dates after June 30, 1997, pregnancies may not be

excluded as a pre-existing condition. In addition, pre-existing clauses may not be

applied to newborns or adopted children who become covered within 30 days of

birth, adoption or placement. This protection is lost if there is a break in

coverage.

3. Certificates

You have a right to request a Certificate of Coverage to qualify for pre-existing

conditions portability or to assist you in gaining new coverage elsewhere.

Certificates must be provided for the following circumstances:

1. an individual loses plan coverage,

2. an individual becomes covered under COBRA,

3. COBRA coverage ceases, or

4. they are requested by the individual no later than 24 months after coverage

ended. This obligation extends for 24 months from the date of the individual's

loss of coverage.

Individuals should request that the prior health plan send certificates directly to

the new employer for proper credit, and should also maintain a copy of the

certificate in his or her records. It is the responsibility of the covered person(s) to

provide this information to the new health plan.

NEW HIRE NOTICE

NEWBORNS’ AND MOTHERS’ HEALTH PROTECTION ACT OF

1996

Effective for plan years beginning on or after January 1, 1998, group health plans and health

insurance issuers offering group health insurance coverage generally may not, under Federal law,

restrict benefits for any hospital length of stay in connection with childbirth for the mother or

newborn child to less than 48 hours following a normal vaginal delivery, or less than 96 hours

following a cesarean section, or require that a provider obtain authorization from the plan or

insurance issuer for prescribing a length of stay not in excess of the above periods.

Attending physicians may discharge the mother and newborn child earlier than 48 hours (or 96

hours for cesarean section) only if done following consultation with the mother, in which the

mother agrees to such early hospital departure.

In any case, plans and issuers may not, under federal law, require that a provider obtain

authorization from the plan or the issuer for prescribing a length of stay not in excess of 48 hours

(or 96 hours).

NEW HIRE NOTICE

WOMEN’S HEALTH AND CANCER RIGHTS ACT OF 1998

In compliance with the Women‟s Health and Cancer Rights Act of 1998, this plan will provide

the following coverages for mastectomies and breast reconstruction:

WOMEN’S HEALTH AND CANCER RIGHTS ACT OF 1998 provides for the following:

In General – A group health plan, and a health insurance issuer providing health insurance

coverage in connection with a group health plan, that provides medical and surgical benefits with

respect to a mastectomy shall provide, in a case of a participant or beneficiary who is receiving

benefits in connection with a mastectomy and who elects breast reconstruction in connection with

such mastectomy, coverage for:

all stages of reconstruction of the breast on which the mastectomy has been performed;

surgery and reconstruction of the other breast to produce a symmetrical appearance; and

prostheses and treatment of physical complications all stages of mastectomy, including lymph

edema; in a manner determined in consultation with the attending physician and the patient.

Such coverage may be subject to annual deductibles and coinsurance provisions as may be

deemed appropriate and as are consistent with those established for other benefits under the

plan or coverage. Written notice of the availability of such coverage shall be delivered to the

participant upon enrollment and annually thereafter.

Prohibitions – A group health plan, and a health insurance issuer offering group health insurance

coverage in connection with a group health plan, may not:

deny to a patient eligibility, or continued eligibility, to enroll or to renew coverage under the

terms of the plan, solely for the purpose of avoiding the requirements of this section; and

penalize or otherwise reduce or limit the reimbursement of an attending provider, or

provide incentives (monetary or otherwise) to an attending provider, to induce such

provider to provide care to an individual participant or beneficiary in a manner

inconsistent with this section.

NOTICE OF PRIVACY PRACTICES

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.

This Notice of Privacy Practices (“Notice”) applies to Protected Health Information

(defined below) associated with Group Health Plans (defined below) provided by

Brigham City Corporation to its employees, its employee‟s dependents and, as applicable,

retired employees. This Notice describes how Brigham City Corporation, collectively

we, us, or our may use and disclose Protected Health Information to carry out payment

and health care operations and for other purposes that are permitted or required by law.

We are required by the privacy regulations issued under the Health Insurance Portability

and Accountability Act or 1996 (“HIPAA”) to maintain the privacy of Protected Health

Information and to provide individuals covered under our group health plan with notice

of our legal duties and privacy concerning Protected Health Information. We are

required to abide by the terms of this Notice as long as it remains in effect. We reserve

the right to change the terms of this Notice of Privacy Practices as necessary and to make

the new Notice effective for all Protected Health Information maintained by us. If we

make material changes to our privacy practices, copies of revised notices will be mailed

to all policyholders then covered by the Group Health Plan. Copies of our current Notice

may be obtained by contacting Brigham City Corporation at the phone number or address

below, or on our benefits web site at www.sterlingbenefits.net.

DEFINITIONS

GROUP Health Plan means, for purposes of this Notice, the following employee

benefits that we provide to our employees, employee dependents and, as applicable,

retired employees:

Protected Health Information (“PHI”) means individually identifiable health

information, as defined by HIPPA, that is created or received by us and that relates to the

past, present, or future physical or mental health or condition of an individual; the

provision of health care to an individual; or the past, present, or future payment for the

provision of health care to an individual; and that identifies the individual or for which

there is a reasonable basis to believe the information can be used to identify the

individual. PHI includes information of persons living or deceased.

USES AND DISCLOSURES OF YOUR PROTECTED HEALTH INFORMATION The following categories describe different ways that we use and disclose PHI. For each

category of uses and disclosures we will explain what we mean and, where appropriate,

provide examples for illustrative purposes. Not every use or disclosure in a category will

be listed. However, all of the ways we are permitted or required to use and disclose PHI

will fall within one of the categories.

Your Authorization – Except as outlined below, we will not use or disclose your PHI

unless you have signed a form authorizing the use or disclosure. You have the right to

revoke that authorization in writing except to the extent that we have taken action in

reliance upon the authorization or that the authorization was obtained as a condition of


obtaining coverage under the group health plan, and we have the right, under other law,

to contest a claim under the coverage or the coverage itself.

Uses and Disclosures for Payment – We may make requests, uses, and the disclosures

of your PHI as necessary for payment purposes. For example, we may use information

regarding your medical procedures and treatment to process and pay claims. We may

also disclose your PHI for the payment purposes of a health care provider or a health

plan.

Uses and Disclosures for Health Care Operations – We may use and disclose your PHI

as necessary for our health care operations. Examples of health care operations include

activities relating to the creation, renewal, or replacement of your Group Health Plan

coverage, reinsurance, compliance, auditing, rating, business management, quality

improvement and assurance, and other functions related to your Group Health Plan.

Family and Friends Involved in Your Care – If you are available and do not object, we

may disclose your PHI to your family, friends, and others who are involved in your care

or payment of a claim. If you are unavailable or incapacitated and we determine that a

limited disclosure is in your best interest, we may share limited PHI with such

individuals. For example, we may use our professional judgment to disclose PHI to your

spouse concerning the processing of a claim.

Business Associates – At times we use outside persons or organizations to help us

provide you with the benefits of your Group Health Plan. Examples of these outside

persons and organizations might include vendors that help us process your claims. At

times it may be necessary for us to provide certain of your PHI to one or more of these

outside persons or organizations.

Other Products and Services – We may contact you to provide information about other

health-related products and services that may be of interest to your. For example, we

may use and disclose your PHI for the purpose of communicating to you about our health

insurance products that could enhance or substitute for existing Group Health Plan

coverage, and a bout health-related products and services that may add value to your

Group Health Plan.

Other Uses and Disclosures – We may make certain other uses and disclosures of your

PHI without your authorization.

We may use or disclose your PHI for any purpose required by law. For example,

we may be required by law to use or disclose your PHI to respond to a court

order.

We may disclose your PHI for public health activities, such as reporting of

disease, injury, birth and death, and for public health investigations

We may disclose your PHI if we believe you to be a victim of abuse, neglect, or

domestic violence.

We may disclose your PHI if authorized by law to a government oversight agency

(e.g., a state insurance department) conducting audits, investigations, or civil or

criminal proceedings.

We may disclose your PHI in the course of a judicial or administrative proceeding

(e.g., to respond to a subpoena or discovery request).

We may disclose your PHI to the proper authorities for law enforcement

purposes.

We may disclose your PHI to coroners, medical examiners, and/or funeral

directors consistent with law.

We may use or disclose your PHI for cadaveric organ, eye or tissue donation.

We may use or disclose your PHI for research purposes, but only as permitted by

law.

We may use or disclose your PHI for research purposes, buy only as permitted by

law.

We may use or disclose PHI to avert a serious threat to health or safety.

We may use of disclose your PHI if you are a member of the military as required

by armed forces services, and we may disclose your PHI for other specialized

government functions such as national security or intelligence activities.

We may disclose your PHI to workers‟ compensation agencies for your workers‟

compensation benefit determinations.

We will, if required by law, release your PHI to the Secretary of the Department

of Health and Human Services for enforcement of HIPAA.

In the event applicable law, other than HIPAA, prohibits or materially limits our users

and disclosures of Protected Health Information, as described above, we will restrict our

uses or disclosure of your Protected Health Information in accordance with the more

stringent standard.

RIGHTS THAT YOU HAVE Access to Your PHI – You have the right of access to copy and/or inspect your PHI that

we maintain in designated records sets. Certain requests for access to your PHI must be

in writing, must state that you want access to your PHI and must be signed by you or

your representative. Access request forms are available from

At the address below, we may charge you a fee for copying and postage.

Amendments to Your PHI – You have the right to request that PHI that we maintain

about you be amended for corrected. We are not obligated to make all requested

amendments but will give each request careful consideration. To be considered, your

amendment request must be in writing, must be signed by you or your representative, and

must state the reason for the amendment/correction request. Amendment request forms

are available from us at the address below.

Accounting for Disclosure of Your PHI – You have the right to receive an accounting

of certain disclosures made by us of your PHI. Examples of disclosures that we are

required to account for include those to state insurance departments, pursuant to valid

legal process, or for law enforcement purposes. To be considered, your accounting

requests must be in writing and signed by you or your representative. Accounting request

forms are available from us at the address below. The first accounting in any 12-month

period is free; however, we may charge you a fee for each subsequent accounting you

request within the same 12-month period.

Restrictions on Use and Disclosure of Your PHI – You have the right to request

restrictions on certain of our users and disclosures of your PHI for insurance payment or

health care operations, disclosures made to persons involved in your care, and disclosures

for disaster relief purposes. For example, you may request that we not disclose your PHI

to your spouse. Your request must describe in detail the restriction you are requesting.

We are not required to agree to your request but will attempt to accommodate reasonable

requests when appropriate. We retain the right to terminate an agreed-to restriction if we

believe such termination is appropriate. In the event of a termination by us, we will

notify you of such termination. You also have the right to terminate, in writing or orally,

any agreed-to restriction. You may make a request for a restriction (or termination of an

existing restriction) by contacting us at the telephone number or address below.

Request of Confidential Communications – You have the right to request that

communications regarding your PHI be made by alternative means or at alternative

locations. For example, you may request that messages not be left on voice mail or sent

to a particular address. We are required to accommodate reasonable requests if you

inform us that disclosure of all or part of your information could place you in danger.

Requests for confidential communications must be in writing, signed by you or your

representative, and sent to us at the address below.

Right to a Copy of the Notice – You have the right to a paper copy of this Notice upon

request by contacting us at the telephone number or address below.

Complaints – if you believe your privacy rights have been violated, you can file a

complaint with us in writing at the address below. You may also file a complaint in

writing with the Secretary of the U.S. Department of Health and Human Services in

Washington, D.C., within 180 days of a violation of your wrights. There will be no

retaliation for filing a complaint.

FOR FURTHER INFORMATION If you have questions or need further assistance regarding this Notice, you can contact

Brigham City Corporation‟s Privacy Office by writing to:


Attn: Privacy Office

20 North Main


435-734-6630

EFFECTIVE DATE This Notice is effective April 14, 2004

Medicare Part D Notice

This is a blanket notice being sent to all employees and COBRA/Mini COBRA enrollees. It is relevant, however, only for individuals entitled to benefits under Medicare Part A or enrolled in Medicare Part B who is enrolled in or seeking to enroll in Brigham City Corporation prescription drug plan. If you are not such an individual, please disregard this notice.

Please read this notice carefully and keep it where you can find it. This notice has

information about your current prescription drug coverage with Brigham City

Corporation and new prescription drug coverage available January 1, 2006 for

people with Medicare. It also tells you where to find more information to help you

make decisions about your prescription drug coverage.

1. As of January 1, 2006, new Medicare drug coverage is available to everyone with Medicare

2. Brigham City Corporation has determined that the prescription drug coverage offered by our group health plan carrier is, on average for all plan participants, expected to pay out as much as the standard Medicare prescription drug coverage will pay.

3. Read this notice carefully – it explains the options you have under Medicare prescription drug coverage, and can help you decide whether or not you want to enroll.

You may have heard about Medicare‟s new prescription drug coverage, and wondered

how it would affect you. Brigham City Corporation had determined that our offered

prescription drug coverage is, on average for all plan participants, expected to pay out as

much as the standard Medicare prescription drug coverage will pay. As of January 1,

2006, prescription drug coverage is available to everyone with Medicare through

Medicare prescription drug plans. All Medicare prescription drug plans will provide at

least a standard level of coverage set by Medicare. Some plans might also offer more

coverage for a higher monthly premium.

Because your existing coverage is on average at least as good as standard Medicare prescription drug coverage, you can keep this coverage and not pay extra if you later decide to enroll in Medicare coverage.

People with Medicare can enroll in a Medicare prescription drug plan anytime before

May 15, 2006. However, because you have existing prescription drug coverage that, on

average, is as good as Medicare coverage, you can choose to join a Medicare prescription

drug plan later. Each year after that, you will have the opportunity to enroll in a

Medicare prescription drug plan between November 15th

through December 31st.

If you do decide to enroll in a Medicare prescription drug plan and drop your Brigham City Corporation prescription drug coverage, be aware that you may not be able to get this coverage back.

If you drop your coverage with Brigham City Corporation and enroll in a Medicare

prescription drug plan, you may not be able to get this coverage back later. You should

compare your current coverage, including which drugs are covered, with the coverage

and cost of the plans offering Medicare prescription drug coverage in your area. You

should also know that if you drop or lose your coverage with Brigham City Corporation

and don‟t enroll in Medicare prescription drug coverage after your current coverage ends,

you may pay more to enroll in Medicare prescription drug coverage later. If after May

15, 2006, you go 63 days or longer without prescription drug coverage that‟s at least as

good as Medicare‟s prescription drug coverage; your monthly premium will go up at

lease 1% per month for every month after May 15, 2006 that you did not have that

coverage. For example, if you go nineteen months without coverage, your premium will

always be at least 19% higher that what most other people pay. You„ll have to pay this

higher premium as long as you have Medicare coverage. In addition, you may have to

wait until next November to enroll.

For more information about this notice or your current prescription drug coverage …

Contact human resources for further information. NOTE: You may receive this notice

at other times in the future such as before the next period you can enroll in Medicare

Prescription drug coverage, and if this coverage changes. You also may request a copy

of this notice from human resources.

For more information about your options under Medicare prescription drug coverage …

More detailed information about Medicare plans that offer prescription drug coverage is

available in the “Medicare & You 2006” handbook. Medicare should have already sent

this handbook to all Medicare-eligible employees. You may also be contacted directly by

Medicare drug plans. You can also get more information about Medicare prescription

drug plans from these places:

Visit www.medicare.gov for personalized help.

Call your State Health Insurance Assistance Program (see your copy of the

Medicare & You handbook for their telephone number).

Call 1-800-MEDICARE ((1-800-633-4227). TTY users should call 1-877-486-

2048.

For people with limited income and resources, extra help paying for a Medicare

prescription drug plan is available. Information about this extra 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 1-800-772-1213 (TTY 1-800-325-

0778).

Remember: Keep this notice. If you enroll in one of the new plans approved by Medicare

which offers prescription drug coverage after May 15, 2006, you may need to give a copy of

this notice when you join to show that you are not required to pay a higher premium

amount.

http://www.medicare.gov/

Notes

Notes

Notes

Sterling Benefit Website

Instructions for Employees

www.sterlingbenefits.net - add to your favorites!!!

Brigham City Corp. Employee Username: brighamcc

Employee Password: sbis

Log on with the above username and password

At the top are several choices: Home, My Benefits, Personal Finance, Your Health and

Sterling Benefits Services – click on each for additional links and information.

Home – provides a brief overview of the website

Newsletter – Hope Health Newsletter – monthly publication provides tips

on healthy eating, fitness, “Doc Talk”, healthy bites and more!

Brigham City Corp. – complete benefit booklet that is available at the

open enrollment meetings, or when an employee is a new hire

My Benefits

Benefit Summaries - a brief summary of the benefits provided by your

employer

Procedures and Forms; Procedures - information on what steps to take for

a specific scenario; Forms – carrier enrollment, change, etc. forms

Provider Links – takes you to the various carrier and provider websites

Personal Finance

Understanding Your Finances

Financial Calculators

Employee Benefit Statement

Shop for Life Quotes

Your Health

Medline Plus

Centers for Disease Control & Prevention

Mayo Clinic

WebMD Health

Sterling Benefit Services

Contact Us – send e-mail directly to Jimmie Jones or Ann Green from website

If you have any questions, or problems logging onto the website, please contact Ann

Green at 801-269-6798, or e-mail: [email protected]. Also, any feedback

would be appreciated!



4525 South Wasatch Boulevard, Suite 250, Salt Lake City, UT 84124

Phone 801.269.6700 Fax 801.269.6767

Documents

Brigham City Corp. · Enrollment Guidelines General Information 1-2 Altius Health Plans Medical 800.377.4161 Procedures for Enrolling Transamerica 2-3 TransConnect / Critical Assistance