2017YOU DECIDE

Annual EnrollmentOctober 17 – November 4, 2016

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TABLE OF CONTENTSTABLE OF CONTENTSWelcome  3

General Eligibility and Enrollment Information EnrollmentandEligibility  4DependentsEligibleForCoverage  4SalaryforBenefitPurposes(AnnualBenefitBaseRate)  4Pre-TaxPremiumsHelpYouStretchYourDollars  5ImportantInformationIfYouAreANewEmployee  5AfterYouEnrollForCoverage  6WhenCoverageBegins  6ConfirmingYourChoices  6ToChangeYourDecisionsAtAnnualEnrollment  7ToChangeYourDecisionsOutsideAnnualEnrollment  7ContinuationofBenefitsDuringLeaveorEndofEmployment  8

Your Flexible Benefit OptionsDentalPlans 10Vision 14Employee,Spouse,andChildLifeInsuranceandAD&D 18Short-andLong-TermDisability 20Long-TermCare 22CriticalIllness 24LegalInsurance 27SpendingAccounts 29

Employee Checklist 32

HIPAA Privacy and Security Notice 33

Benefit Phone Directory 35

Terms and Conditions 36

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WelcmeWelcome toTHE STATE OF GEORGIA FLEXIBLE BENEFITS PROGRAM

TheStateofGeorgiaispleasedtoofferyouacompetitiveflexiblebenefitsprogramasanintegralpartofyourTotalRewardspackage.Your2017YOU DECIDEbookletgivesyouanopportunitytoreviewandunderstandtheseplans.Itsummarizestheoptionsavailabletoyouandyoureligibledependents,alongwithwhatyouneeddotoobtainthesebenefits.

Areyouplanningorexpectingthebirthoradoptionofachild?Gettingmarriedsoon?Areyoucaringforanagingparent?Isittimetostartthinkingaboutsupplementingyourretirement?Thesearejustsomeoflife’schangesthatcouldaffectthehealthcareandfinancialneedsofyouandyourfamily.

The2017planyearincludessomeenhancements,soreviewallyourmaterialscarefully.PleasereadtheYOU DECIDE booklettounderstandtheoptionsavailabletoyouandguideyouinmakingthechoicesthatbestmeetyourneeds.Makingtherightdecisionstodaycanmakearealdifferencetowardbuildingasecurefutureforyouandyourfamilytomorrow.

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Enrollment and Eligibility

YouareeligibletoparticipateintheFlexibleBenefitsProgramifyouare:• Afull-time,regularemployeewhoworksatleast

30hoursaweekandisexpectedtoworkforatleastninemonths.Employeeswhoworkinashelteredworkshoporworktransitionprogram,contingentemployees,temporaryemployees, andstudentemployeesarenoteligible.

• Apublicschoolteacher,workingatleast17.5hoursperweek,andemployedinaprofessionallycertifiedcapacity,workinghalftimeormoreandnot considered a “temporary” or “emergency” employee.

• Anemployeeofalocalschoolsystemholding anon-certificatedposition.YoumustbeeligibletoparticipateintheTeacher’sRetirementSystem(TRS)oritslocalequivalent,andyoumustworkaminimumof20hoursaweek(or60%ofthetimenecessarytocarryoutthedutiesoftheposition, ifthat’smorethan20hours).

• Anemployeeofalocalschoolsystemworkingatleast15hours(or60%ofthetimenecessarytocarryoutthedutiesofyourposition,ifthat’smorethan15hours)andyouareeligibletoparticipateinthePublicSchoolEmployees’RetirementSystem(PSERS).

• Anemployeeofacountyorregionallibrary andworkatleast17.5hoursperweek.

• Deemed eligible by Federal or Georgia law.

Ifyouaren’tsurewhetheryou’reeligible,contactyourHumanResources/PayrollOffice.

Dependents Eligible For Coverage

Eligibledependentsincludeyour:• Legalspouse.• Dependentchild/renwhoareunderage26.• Dependentchild/renwhoareage26oroverand

incapableofself-sustainingemploymentbyreasonofmentalincapacityorphysicaldisability.

• Dependentchild/renaredefinedasyouoryourspouse’snaturalorlegallyadoptedchild/ren.Toverifyeligibilityofnewlyaddeddependents,youmustprovidesupportingdocumentation(e.g.,birthcertificate,marriagecertificate),ifrequested.

Salary for Benefit Purposes (Annual Benefit Base Rate)

YourAnnualBenefitBaseRateincludesyourbase salaryandsalarysupplementsthatareregular,non-temporary,andnotmorethantheamountonwhichretirementcontributionsarecalculated.ThisamountisreflectedonGaBreezeandremainsconstantfortheentireplanyear.ItiscalculatedonyourdateofhireandupdatedeachOctober1thereafter(theBenefitCalculationDate).AnyadjustmentstoyourAnnualBenefitBaseRate,withtheexceptionoferrors(asdeterminedbythePlanAdministrator),shallbereflectedonthefollowingBenefitCalculationDateandeffectiveforthefollowingplanyear.Promotions,demotions,andadjustmentsduetocertificationsarenotdeemedtobeerrors.YourAnnualBenefitBaseRateisthepayusedtocalculateyourcoverageforemployeelife,AD&D,anddisabilityinsurance.

BenefitsareakeypartofyourTotalRewards.PleasenotethatyourAnnualBenefitsBaseRateasofOctober1maybedifferentfromyourregularsalary.

GENERAL ELIGIBILITY AND ENROLLMENT INFORMATION

The“TotalRewards”website,accessedthroughGaBreeze,hasbeenenhancedandisnowupdatedonamonthlybasis.Tocheckoutthenewsite,gotowww.team.ga.govandclickonMy Benefits followed by Flexible Benefits toaccessGaBreeze.ThenlookintheupperrighthandcornerforthelinktoYour Total Rewards.

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Pre-Tax Premiums Help You Stretch Your Dollars

TheFlexibleBenefitsProgramallowsyoutosaveontaxeswhileyoupayforyourbenefits.Pre-taxpremiumsreduceyourtaxableincome–which,inturn,reducesyourtaxes.That’sbecausecertainpremiums(dental,vision,and,atyourdirection,lifeinsurance),andSpendingAccountcontributionsaretakenoutofyourpaybefore federal and state income taxesandSocialSecurity(FICA)taxesarewithheld.

Theresult?Yourtaxableincomeislowerandso areyourtaxes.Italsomeansyouhavemorein yourpaycheck–ormoretospendonbenefitsthanyouwouldifyou’dpaidthesamepremiumswithpost-taxdollars.

Important Information for New Hires

Ifyouareanewemployee,lookcarefullyatthoseFlexibleBenefitsthatofferone-timeopportunities.

• New Hire Electronic Enrollment Youwillreceiveanenrollmentworksheet,mailed

toyourhomeaddress,toprepareyoutoenroll.Youcanselectyourbenefitsusingtheemployeewebsite, www.GaBreeze.ga.gov or by accessing theTeamGeorgiaConnection(www.team.ga.gov)byclickingFlexible BenefitsundertheMy Benefitstab,orcallingtheGaBreezeBenefitsCenterat1-877-342-7339.

• Dental Thereisasix-monthwaitingperiodforMajor

servicesundertheSelectPlanandasix-monthwaitingperiodforMajorandOrthoservicesundertheSelectPlusplan.TheDHMOoptiondoesnothavewaitingperiodsorlateenrollmentpenalties,butrequiresthatyouuseaDHMOnetworkprovider. Go to www.cigna.com for a list of DHMOnetworkproviders.

• Spending Accounts YourcontributionstoSpendingAccountswillstart

onthe15thdayofyourfirstfullcalendarmonthofemployment.Formonthlypayrolls,thefullreductionwillbetakenonceamonthafteryourfirstfullcalendarmonthofemployment.Yourtotalcontributionstoeachaccountareproratedbythenumberofmonthsyouparticipateintheseoptions,uptothemaximummonthlyamountallowedforeachaccount.Onceyouenroll,youmaysubmitclaimsforservicesincurredonorafterthefirstofthemonthafteryouhavecompletedonefullcalendarmonthofemployment.

• Long-Term Care Youhaveaone-timeopportunitytosignup

forLong-TermCareinsurancewithoutprovidingevidenceofinsurability.

• Employee Life, Spouse Life, and Child Life Youhaveaone-timeopportunitytochoose

designatedlevelsofemployeeandspouselifeinsurancecoveragewithoutprovidingevidence ofinsurability.PleaseseetheEmployee,Spouse,andChildLifesectionforspecificlimits.

• Employee Critical Illness and Spousal Critical Illness Youhaveaone-timeopportunitytosignupforguaranteedlevelsofCriticalIllnessinsurance,upto$30,000,withoutprovidingevidence of insurability.Coverageforchildrenisincluded withtheEmployeeBenefit.

Youalsohaveaone-timeopportunitytosignupforSpousalCriticalIllnesscoverage,guaranteedupto$30,000,withoutprovidingevidenceofinsurability.

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GeneralEligibilityandEnrollmentInformation• Disability Duringyournew-hireeligibilityperiod,youhave

aone-timeopportunitytosignupforlong-termdisabilitycoveragewithoutprovidingevidenceofinsurability.Ifyoudonotenrollwithinthis30-dayperiod,youwillneedtocompleteanevidenceofinsurabilityform.Yourrequestedlong-termdisabilitycoveragewillnotbecomeeffectiveuntilyourevidenceofinsurabilityisapprovedbyStandardInsuranceCompany(TheStandard).

Duringyournew-hireeligibilityperiod,youhaveaone-timeopportunitytosignupforshort-termdisabilitycoveragewithoutbeingsubjecttoalateentrantwaitingperiod(LateEnrollmentPenalty). Ifyoudonotenrollwithinthis30-dayperiod, youwillbesubjecttotheLateEnrollmentPenalty.

• Other Coverage Therearenomedicalunderwritingrequirements

atanytimeforlegalinsurance,AD&D,spendingaccounts,anddentalandvisionbenefits.

After You Enroll For Coverage

Besuretoconsideryouroptionscarefullywhenyoufirstenroll.IfyoudeclineordropsomeofyourStatecoveragesandwanttopickthemupagaininafutureAnnualEnrollment,youmayhavetoproveinsurabilitythroughmedicalunderwritingtobecoveredagain,orhavetocompletelongerwaitingperiodstoreceivefullbenefits.

When Coverage Begins

Ifyouareanewemployee,yourbenefitselection(s)andanynecessaryformsmustbecompletednolaterthan30daysafteryourhiredate.Yourcoveragewillbeginonthefirstdayofthemonthafteryouhavecompletedafullcalendarmonthofcontinuousemployment.

CoveragefornewoptionsselectedduringAnnualEnrollmentwillbeginonJanuary1stofthefollowingyear,aslongasyouhavemetallcontractualandadministrativerequirements.

Yournewspendingaccountreductionsbeginonthe15thofthemonth;otherpremiumsaretakenat theendofthemonth(forsemi-monthlypayperiods).Thesedatesmaynotapplyifyourdepartmenthasadifferentpayschedule.PleasecheckwithyourHumanResources/PayrollOfficeformoreinformation.Seespecificplandescriptions forinformationaboutwhenyourcoveragebegins.

Confirming Your Choices

Youareresponsibleforselectingthebenefitsyouwantbyeither:• EnteringselectionsontheGaBreezewebsite,or• CallingtheGaBreezeBenefitsCenterand

verbalizingyourselections.

Itiscrucialthatyouprintyourconfirmationandverifyyourselectionsbeforetheendoftheenrollmentperiod.ThebenefitelectionsreflectedontheStatementwillbeineffectfortheentireplanyear.TheConfirmationStatementdoesnotguaranteeyourcoverageforplansthatrequiresubmissionofadditionalinformation.Ifyouhavenotcompletedandsubmittedtheformsorotherinformationrequiredforyourselectedplan(s),thechoicesshownonyourConfirmationStatementmaynotbevalid.

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CompareyourpaycheckstatementswithyourConfirmationStatement.Deductionsshouldmatchtheconfirmedchoices.Shouldyoufindanydiscrepencies,itisyourresponsibilitytonotifyyourHumanResources/PayrollOfficeimmediately.AnychangesinbenefitsmustbeinaccordancewithIRS§125,EmployeeBenefitsPlanCouncilrulesandregulationsandbeapprovedbyplanadministrators.

To Change Your Decisions at Annual Enrollment

EachAnnualEnrollment,youcanchangeyourbenefitdecisionsbasedonwhichoftheavailableoptionsarebestforyouandyourfamily.Remember,thisisanannualagreementallowingtheStatetopurchaseselectedbenefitsforyou,asdescribedinthisbooklet,throughpre-taxpremiums.(Note:notallbenefitsareavailableonapre-taxbasis.)Youwill notbeabletochangebenefitelectionsuntilthe nextAnnualEnrollment–unlessyouhaveaqualifyingchangeinstatus,asdescribedinthe TermsandConditions.

Fornewhires,ifyouhavemadeyourbenefitdecisionsontheGaBreezewebsiteandwishto makeachangewithinyour30-dayenrollmentwindow,youwillneedtocontacttheGaBreezeBenefitsCenterat1-877-342-7339.

To Change Your Decisions Outside of Annual Enrollment

Qualifying Change in Status EventIngeneral,theInternalRevenueServiceprohibitsyoufromchangingcoverageelections,orenrollinginorcancelingcoverageundertheFlexibleBenefitsProgram,outsideofAnnualEnrollment.However,therulesoftheInternalRevenueServiceandtheEmployeeBenefitsPlanCouncildopermityoutochangecoverage,enroll,orcancelcoverageincertainlimitedcircumstances,ifthechangecorrespondstoaqualifyingchangeinstatusevent.

YourrequestforenrollmentorachangeincoverageundertheFlexibleBenefitsProgrammustbeenteredontheGaBreezewebsite,orbycallingtheGaBreezeBenefitsCenter,within30daysafterthequalifyingevent.Therewillbenorefundofpremiumspaidintotheplanwhenatimelychangeisnotmade.

Generally,benefitchangeswillgointoeffectonthefirstdayofthemonthfollowingtherequestwhenthepayrolldeductionischangedtoreflectyournewchoices.Forsomebenefits,however,whenyouchangecoveragebasedontheacquisitionofdependents,theeffectivedateforthecoveragemayberetroactivetothedateofthequalifyingevent,ormaybethefirstofthemonthfollowingtherequesttochangecoverage.

30-Day WindowIfyouhaveaqualifyingchangeinstatus,theIRSallowsyoualimitedperiod–30days–tomakeapplicablebenefitchanges.Inmostcases(e.g.,birthoradoption),ifyoumakeyourbenefitchangeswithinthe30-daywindow,theywillbebackdatedtothedateofthequalifyingevent.Ifyoudonotdosowithin30days,youwillhavetowaituntilthefollowingAnnualEnrollmenttoupdateyourbenefits.

Examples of Qualifying Changes in Status• Marriageordivorce• Birth,adoption,orlegalguardianship• Deathofadependent• LossofspousalcoverageFor more information, see Terms and Conditions, pp. 36-37.

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Separation From Service

• Unpaid Leave Whenyougoonleavewithoutpay,youwill

receiveabillfromGaBreezeforyourbenefitscoverage.Ifyoudonotcontinuepayingthesepremiums,yourbenefitswillbecancelledandyoumaybesubjecttopenaltiesandwaitingperiodswhenyouseektoreinstatethem.YoumayalsoberequiredtowaituntilthenextAnnualEnrollmentperiodtore-enroll.BesuretoreviewPlanDescriptionsforeachoption.UnpaidFamilyMedicalLeave(FML)andMilitaryLeavewillbehandledinaccordancewithapplicablelaws.

• Retirement Itistheemployee’sresponsibilitytocontactthe

providerdirectly,withintherequiredtimeframe,tocontinuecoverageforEmployee/Spouse/ChildLife,AD&D,Long-TermCare,Long-TermDisability,Employee/SpouseCriticalIllness,orLegalInsurance,asapplicable.Ifyouretireandarecurrentlyenrolledindental,yourcoveragewillcontinueautomatically.Ifyouwishtocancelyourdentalcoverage,contacttheGaBreezeBenefits

Center.(Pleasenotethat,oncecancelled,dentalcoveragecannotbereinstated.)Ifyouwish,youmaycontinueyourHealthCareSpendingAccount(HCSA)throughCOBRA.

• Breaks in Employment IfyouleaveactiveStateemploymentbutreturn

withina30-dayperiodduringthesameplanyear,yourpreviousbenefitchoiceswillremainineffectunlessyoureportaqualifyingchangeinstatusevent.IfyouleaveactiveStateemploymentandreturninthesameplanyearbeyonda30-dayperiod,youwillbetreatedasanewhireandmustmakenewbenefitelections.Ifyouretiredandarearehirereturningtoabenefits-eligibleposition,youmustre-electdentalinordertocontinuecoverage.

• Termination of Employment IfyoustopworkingfortheState,yourbenefits

typicallyend30daysafteryourmostrecentpremiumorcontributionhasbeenpaid.Seep.9foralistofbenefitseligibletobecontinued,onapost-taxbasis,eitherthroughCOBRAorbyarrangementwithacarrier.

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Can I take Insurance Coverage with me when I terminate employment?

Benefits

Dental Coverage

Select&SelectPlus

DHMOOption

Vision Coverage

Health CareSpending Accounts

Dependent (Child) Care Spending Account

Employee/Spouse/Child Life Insurance

AD&D Insurance

Critical Illness

Disability Coverage

Short-Term   Long-Term

Legal Insurance

Long-Term Care Insurance

Retiree Coverage Available Through

Retirement Plan Benefit Deductions

Yes

Yes

No

No

No

No

No

No

No

No

No

No

Coverage Can Be Continued

Through COBRA

Yes

Yes

Yes

Yes(throughendof theplanyear)

No

No

No

No

No

No

No

No

You Must Decide and Complete

Carrier Forms Within

COBRA 60days

Convert within31days(DHMOonly)

60days

60days

N/A

31days

31days

31days

N/A

31days

30days

60days

Coverage Can

Be Direct Billed by Carrier or Converted to an Individual

Policy

No

Yes

No

No

No

Yes

Yes

Yes

No

Yes

Yes(for30months)

Yes

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YOUR FLEXIBLE BENEFIT OPTIONS

DentalYoucanchooseamongthreedentalplans:• CignaDentalCare®(DHMO)• Delta Dental Select • DeltaDentalSelectPlus

Eachhasdifferentpaymentschedulesandproviders.Closelyreviewtheseplanstodeterminewhichonebestfitstheneedsofyouandyourfamily.Usethecomparisonchartinthisguidetolearnabouttheplans.Duetoavailability,yourbestbenefitoptionmaydependonwhereyouliveorwork,sobesuretochecktheavailabilityofdentistscarefully.Forexample:

• Cigna Dental Care® (DHMO) –designedspecificallyforemployeeswholiveorworkinmetropolitanAtlantaandotherdesignatedareas.

• Delta Dental Select and Delta Dental Select Plus–forotheremployeesthroughoutGeorgia

Cigna Dental Care ® (DHMO) Plan

Cigna Dental Care® (DHMO)planfeatures:

• Nodeductiblestopaybeforeyoucanuse yourplan

• Noannualdollarmaximumsthatlimitbenefits• Noclaimformstofile• NoIDcardsrequiredtoreceivecare• Noagelimitonsealantstopreventcavities• Noreferralsrequiredtovisitanetwork

orthodontistorforchildrenunderseven tovisitanetworkpediatricdentist

TheCignaDHMOisavailabletoemployeeswholiveorworkinmetropolitanAtlantaandotherdesignatedareas.WiththeCignaDHMO,you’llknowexactlywhatyou’llpay(“copays”)forcoveredservices–evenforspecialtycarewithareferralapprovedforpayment.JustchooseageneraldentistfromtheCignaDHMOnetworkatenrollmentandvisitthatdentistforallyourdentalcareneeds.Networkdentistsaren’tallowedtochargeyoumorethantheco-payforcoveredservices.Mostpreventiveservices,suchasexams,x-raysandcleanings,arecovered100%(frequencylimitsmayapply).Dentaltreatments,suchasfillings,crownsandrootcanalsarecoveredatreduced,fixedco-pays.

Keep in mind that there is no out-of-network coverage with a DHMO plan.ButfindinganetworkdentistnearyouiseasywhenyouusetheProvider Directory at www.cigna.comandclickonFind a Doctoratthetopofthescreen.ThenselectIf your insurance plan is offered through work.Next,clickFind a . . . Dentist.Enterthegeographiclocationyouwanttosearch–bycity,state,orzipcode.Clickon Select a Plan, and select Cigna Dental Care HMO undertheDental Planssection.Then,pressChoose. Yourcoveredfamilymemberscaneachselecttheirowngeneraldentists.Afteryouenroll,youcanchangeyourgeneraldentistatanytime–onlineorbyphone.

• Cigna Dental Oral Health Integration Program® Thisprogramreimbursesout-of-pocketcosts

forspecificdentalservicesusedtotreatorhelppreventgumdiseaseandtoothdecay.Theprogramisforpeoplewithcertainmedicalconditionsthatmaybeimpactedbydentalcare.

Theonlyrequirementisthatyou’recurrentlybeingtreatedbyadoctorforheartdisease,stroke,diabetes,headandneckcancerradiation,maternity,chronickidneydisease,ororgantransplant.

ForadditionalinformationregardingCigna’s OralHealthIntegrationProgram,pleasevisit www.cigna.com.

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Cigna Dental Care DHMO Plan

In Network

Reduced,fixed,presetchargesforallcoveredservices.SeeyourpatientChargeScheduleforSpecificCharges(amalgam[silver]fillingsonly)

Reduced,fixed,presetchargesforallcoveredservices.SeeyourpatientChargeScheduleforSpecificCharges(amalgam[silver]fillingsonly)

Reduced,fixed,presetchargesforallcoveredservices.SeeyourpatientChargeScheduleforSpecificCharges

Reduced,fixed,presetchargesforallcoveredservices.SeeyourpatientChargeScheduleforSpecificCharges

NONE

NoMaximum

NoWaitingPeriod

Benefits & Covered Services

Type IDiagnostic&PreventiveServicesOralExams,Cleanings,X-rays,

Type IIBasic Services Fillings,RootCanals,Extractions,Scalingand RootPlanning,RepairstoDentures,Bridges and Crowns Sealants

Type IIIMajorCrowns,Dentures,Bridgework, SurgicalPeriodontal

Orthodontic BenefitsCephalometricX-rays,TreatmentXtudy,Bands,Appliances

Annual Deductible

Maximum Benefits

Waiting Period for Benefits

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Delta Dental Select and Delta Dental Select Plus IfyouchooseaSelectorSelectPlusplanwith DeltaDental:

• Youmaygotoanydentist.

• IfyouvisitaDeltaDentalPPOnetworkdentist,theyacceptreducedfeesforcoveredservices,soyou’llusuallypaytheleastwhenyouvisitaPPOnetworkdentist.ThisprovisionalsoensuresthatDeltaDentalPPOdentistswon’tbalance-billyouthedifferencebetweenthecontractedamountandtheirusualfee.

• Ifyouvisitnon-DeltaDentalnetworkdentists,theycanbalancebillyouthedifferencebetweentheamountofbenefitspayablebyDeltaDental andthedentistchargeforthatservice.

• Note:Orthodontiaservicesforadultsanddependentchildrenareavailableonlythrough theSelectPlusPlan.

Important Information for Select and Select Plus Options

Six (6) Month Wait PeriodAllNewHiresaresubjecttotheSix(6)MonthWaitPeriodforMajor(TypeIII)andOrthodontiaservices(foradultsandchildrenundertheSelectPlusPlan).

Ifacurrentemployeeselectsdentalforthefirsttime,theyandanyeligibledependentswillberequiredtomeettheSix(6)MonthWaitPeriodforTypeIIIandOrthodontiaservices(foradultsandchildrenundertheSelectPlusPlan).

IfanemployeeswitchesfromtheSelecttotheSelectPlusoption,theyandanyeligibledependentswillberequiredtomeettheSix(6)MonthWaitPeriodforTypeIIIandOrthodontiaservices(foradultsandchildrenundertheSelectPlusPlan).

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Delta Dental PPO

Eligibility Primaryenrollee,spouseandeligibledependentchildrentoage26

$50perperson/$150perfamilyeachcalendaryearDeductibles* *DeductibleiswaivedforDiagnostic&Preventative

$500perpersoneachcalendaryearDentalSelectPlanMaximums* $2,000perpersoneachcalendaryearDentalSelectPlusPlan *Diagnostic&Preventativedoesnotcounttowardsthemaximum

BasicBenefits MajorBenefits OrthodonticsWaiting Period(s) 0Months 6Months 6Months–PlusPlanOnly

 *IfyouswitchplansduringthecalendaryearyourDeductibleandAnnualMaximummaybeadjustedaccordingly.**Limitationsorwaitingperiodsmayapplyforsomebenefits;someservicesmaybeexcludedfromyourplan.Reimbursementisbased onDeltaDentalcontractallowancesandnotnecessarilyeachdentist’sactualfees† ReimbursementisbasedonPPOcontractedfeesforPPOdentists.PremiercontractedfeesforPremierdentistsand80thpercentile fornon-DeltaDentaldentists.

Delta Dental Insurance Company Customer Service Claims Address1130SanctuaryParkway,Suite600 866-496-2384 P.O.Box1809Alpharetta,GA30009 www.deltadentalins.com Alpharetta,GA30023-1809

Thisbenefitinformationisnotintendedordesignedtoreplaceorserveastheplan’sEvidenceofCoverageorSummaryPlanDescription.Ifyouhavespecificquestionsregardingthebenefits,limitationsorexclusionsforyourplan,pleaseconsultyourcompany’sbenefitsrepresentative.

Dental Select Plan Dental Select Plus Plan

Benefits and PPO Premier Non-Delta PPO Premier Non Covered Services** Dentists Dentists Dental Dentists Dentists Delta Dentists

Diagnostic&Preventive Services(D&P) 100% 100% 100% 100% 100% 100% Exams,cleanings,x-rays

Basic Services Fillings,simpletootextractions 80% 80% 80% 90% 90% 90% sealants

Endodontics(rootcanals) CoveredUnderBasicServices 80% 80% 80% 90% 90% 90%

Periodontics(gumtreatment) CoveredUnderBasicServices 80% 80% 80% 90% 90% 90%

OralSurgery CoveredUnderBasicServices 80% 80% 80% 90% 90% 90%

MajorServices  Crowns, inlays, onlays and cast 50% 50% 50% 60% 60% 60%  restorations,bridges,dentures&  TMJ,surgicalperiodontics

OrthodonticBenefits Not Not Not  adultsanddependentChildren Covered Covered Covered 50% 50% 50%

OrthodonticMaximums Not Not Not  Lifetime Covered Covered Covered $2,000 $2,000 $2,000

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VisionVisioncoverageisavailablethroughBlueCrossBlueShieldofGeorgia.Youhaveachoicebetweentwoplanoptions–VisionSelectPlanandVisionSelectPlusPlan.Bothplansofferthesefeatures:• Coveredexamsandmaterials• Statewideaccesstoanetworkofproviders• Noclaimstofilefor“in-network”benefits• Benefitsfor“out-of-network”providers.

TheBlueCrossBlueShieldorGeorgiaVisionCareparticipatingprovidernetworkincludesbothprivatepracticeophthalmologistsandretailchains.Manyproviders–includingretailchains–areopeneveningsandweekends.ParticipatingretailchainprovidersincludeLensCrafters,TargetOptical,JCPenneyOptical,SearsOptical,Walmart,PearleVision,and1-800-Contacts,amongothers.

Tolocateparticipatingprivateproviders,justgotowww.bcbsga.com:• ClickFind a Doctor• ChooseyourState(GA)• Scroll down to Vision and select Blue View Vision.

Your Plan Options

• Vision Select Plan TheVisionSelectPlancoversstandardsingle

visionandstandardlinedmulti-focallensesforglasses.Cosmeticlensoptions,suchastinting,UVcoating,andtransitionallensesarenotcovered,butareavailableatdiscountedrates.

Certainstandardcontactlenses,includingdailywear,anduptofourboxesofstandardsinglevisiondisposablecontacts,arecoveredinfullbycopays.UndertheVisionSelectPlan,ifyoupurchasecontactsthatarenotamongBlueCrossBlueShieldofGeorgiaVision’s“coveredinfull”selection,youwillreceiveanannual$105allowancetowardthepurchaseofcontactlenses,andprofessionalservices(e.g.,fitandfollow-up).

Toreceivethefull$105allowanceundertheVisionSelectPlan,youmustreceiveyourexam,fitting,andevaluationduringasinglevisittothesamenetworkprovider.Theallowancewillapplyonlytoonepurchaseperplanyear.

Ifyouuseanon-networkprovider,youmustsubmitallreceiptsatthesametime.Anybalanceremaining,andnotusedduringtheplanyearwhenthepurchaseoccurred,willbeforfeited.

• Important Information for the Vision Select Plan Benefitsareprovidedevery12monthsforexams,

lensesand/orcontacts,andforframes,basedonthelastdateofservice.Theout-of-networkallowanceforcontactlensesis$105.

Note:Benefitservicelimitationsarecalculatedonacalendaryear.Example:ifyoureceiveexamservicesinMarch,youwillbeeligibletoreceiveanotherexaminJanuaryofthefollowingyear.

Ifyouchoosecontactlenses,nobenefitswillbeavailableforcoveredeyeglasslensesduringthatperiod.

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* If you choose contact lenses, no benefits will be available for covered eyeglass lenses during that period.

Vision Select Plan

 COVERED SERVICES COPAYMENTS/MAXIMUMS

Network Providers Non-Network Providers

Eye ExamLimitedtooneexamper $10Copayment Reimbursedupto$40 MembereveryCalendarYear

Prescription Lenses $20CopaymentLimited to one set of lenses perMembereveryCalendarYear

Basic Lenses (Pair)• SingleVisionlenses Reimbursedupto$40• Bifocallenses Reimbursedupto$60• Trifocallenses Reimbursedupto$80• Lenticularlenses Reimbursedupto$80

Includes:• Factoryscratchcoating• Tint(solidandgradient)• PolycarbonateandPhotochromic

lenses(forchildrenunderage19)• UVcoatings

FramesLimitedtoonesetofframes NoCopayment Reimbursedupto$45perMembereverytwoyears AllowableAmountupto $130retailallowance

Prescription Contact Lenses* No Copayment (traditionalordisposable)

• Non-ElectiveContactLenses Coveredinfull Non-Networkproviders (OnceeveryCalendarYear) arereimbursedupto$210

• ElectiveContactLenses NoCopayment Non-Networkproviders (OnceeveryCalendarYear) $105retailallowance arereimbursedupto$105

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• Vision Select Plus Plan InadditiontothecoverageintheVisionSelect

Plan,theVisionSelectPlusPlanofferscosmeticlensoptionsforTints,UV,Polycarbonate,andBasicProgressivelenses.

Toreceivethefull$200allowanceundertheVisionSelectPlusPlan,youmustreceiveyourexam,fitting,andevaluationduringasinglevisittothesamenetworkprovider.Theallowance willapplyonlytoonepurchaseperplanyear. Youmustsubmitallreceiptsatthesametime. Anybalanceremaining,andnotusedduring theplanyearwhenthepurchaseoccurred, will be forfeited.

• Important Information for the Vision Select Plus Plan

BenefitsareprovidedeveryCalendarYearforexams,lensesand/orcontacts,andforframesmeasuredfromthelastdateofservice.Theout-of-networkallowanceforcontactlensesis$200.

Note:Benefitservicelimitationsarecalculatedonacalendaryear.Example:IfyoureceiveexamservicesinMarch,youwillbeeligibletoreceiveanotherexaminJanuaryofthefollowingyear.

IfyouchoosecoveredNon-ElectiveContactLensesorElectiveContactLenses,nobenefitswillbeavailableforcoveredeyeglasslensesinthatperiod.

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* If you choose contact lenses, no benefits will be available for covered eyeglass lenses during that period.

Vision Select Plus PlanCOVERED SERVICES COPAYMENTS/MAXIMUMS

Network Providers Non-Network Providers

Eye ExamLimitedtooneexamper $10Copayment Reimbursedupto$40MembereveryCalendarYear

Prescription LensesLimited to one set of lenses per MembereveryCalendarYear Basic Lenses (Pair) $25Copayment• SingleVisionlenses Reimbursedupto$40• Bifocallenses Reimbursedupto$60• Trifocallenses Reimbursedupto$80• Lenticularlenses Reimbursedupto$80

Includes the following Lens Options: • Factoryscratchcoating• UVcoating• Tint(solid&gradient)• Polycarbonatelenses• TransitionsPhotochromiclenses• Standard&PremiumProgressivelenses• StandardAnti-Reflectivecoating(Not

CoveredForNon-NetworkProviders) Frames Limitedtoonesetofframes NoCopayment Reimbursedupto$45perMembereveryCalendarYear AllowableAmountupto $150retailallowance

Prescription Contact Lenses* (traditionalordisposable) NoCopayment

• Non-ElectiveContactLenses Coveredinfull Non-Networkproviders (OnceeveryCalendarYear) arereimbursedupto$210

• ElectiveContactLenses NoCopayment Non-Networkproviders (OnceeveryCalendarYear) $200retailallowance arereimbursedupto$200

Still have questions? PleasecontactGeorgiaBreezeorBlueCrossBlueShieldofGeorgiaVisionCustomerServiceat1-855-556-4844.

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Employee, Spouse, Child Life, and Accidental Death & Dismemberment Insurance Ifyouwantlifeinsuranceprotection,orwanttosupplementthecoverageyoualreadyhave,you maychooseMetLifegrouptermcoverageunder theFlexibleBenefitsProgram.Theamountyou selectispaidtothebeneficiariesyounameto receivethesebenefitsshouldyoudiewhilethiscoverageisineffect.

Your 2017 Annual Enrollment• Employee Life Coverage–abilitytoelectbenefits

ofoneto10timesyourpay,upamaximumbenefitof$2,000,000.YouhavetheoptiontopaypremiumsforEmployeeLifeonapre-taxorpost-taxbasis.(Note:Coverageisreducedstartingatage65.)

Note:During2017AnnualEnrollment,youmayincreaseyourcoveragebyone-timespay,guaranteed,withouthavingtoprovideevidence ofinsurability.

• Premium Waiver–providescontinuationofEmployeeLifeinsuracewithoutpremiumpaymentshouldyoubecomedisabled.

• Will Preparation Service–allowsyoutoconsult,inpersonorviaphone,withaparticipatingHyattLegalplanattorney,whowillcompleteawill,livingwill,orpowerofattorneyforyouandyourlegalspouse,atnochargetoyou.

• Estate Resolution Services–givesyourbeneficiariesthesupportofaHyattLegalplanattorney,in-personorviatelephone,todiscussmattersrelatedtoprobatingyourestate.

If You are a New Employee

Asanewhire,youhaveaone-timeopportunitytoelectcertainlevelsofemployeeandspouselifeinsurance,guaranteed,withouthavingtoprovideevidenceofinsurability.

Coverageforyouisavailableinincrementsofyourpay–fromoneto10timespay,upto$2,000,000.Amountsofone-timespay,upto$200,000,areissued,guaranteed.Higherlevelsofcoveragewillbesubjecttoevidenceofinsurability.

Childlifeinsuranceandupto$30,000ofspouselifecoverageisalsoavailable,guaranteed,withoutneedtoprovideevidenceofinsurability.

• Spouse Life Insurance Ifyouchooseemployeelifeinsuranceforyourself,

youmayalsoselectcoverageforyourspouse.Spouselifeinsurancepremiumsarebasedon thecoveragelevelandyourage.YourpremiumsforSpouseLifearepaidonanpost-taxbasis. (Ifyouare65orolder,theamountofyourspouselifecoverageisreduced.)

SpouseLifecoveragecannotexceed100%ofyouramountofEmployeeLifecoverage.

Youarethebeneficiaryofspouselifeinsurancecoverageandwillreceivetheinsurancebenefit intheeventofyourspouse’sdeath.

• Child Life Insurance Ifyouchooselifeinsuranceforyourself,you

mayalsoelectchildlifeinsuranceforyourchild(ren)underage26.Thiscoverage,whichisissuedguaranteed(withoutneedformedicalunderwriting),ispaidforonanpost-taxbasis.

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Important Notes about Child Life: Childcoveragebeginsatlivebirth.Coveragefromlivebirthtosixmonthsisthelesseroftheelectedamountor$6,000.Fromsixmonthsofagetoage26,thefullelectedamountapplies.

• ChildLifecoveragecannotexceedyouramountofEmployeeLifebenefits.

• Youarethebeneficiaryofchildlifeinsurancecoverageandwillreceivethebenefitintheeventofthechild’sdeath.

• Accidental Death and Dismemberment Insurance TheFlexibleBenefitsProgramoffersaccidental

deathanddismemberment(AD&D)insurancetobepaidtoyouoryourbeneficiaryifyourinjuryordeathistheresultofacoveredaccident.Incaseofpermanentandtotaldisability,youareeligibleforAD&Dbenefitsifyourinjurypreventsyoufromworkingatanyjobforwhichyouarequalifiedbyeducation,training,orexperience.

Youmayelectcoverageinincrementsofyourpay

–fromoneto10timespay,upto$2,000,000.YourpremiumsforAD&Darepaidonapre-taxbasis.(Ifyouareage75orolder,thiscoverageisreduced.)

• Important Notes about Employee, Spouse, Child Life and AD&D Insurance

ThelifeandAD&DinsuranceamountsyouchoosewillbebasedonyourAnnualBenefitBaseRateasofOctober1.Thisamountisroundeduptothenexthigher$1,000,afteryoumultiplyyourcoverageandadjustforagereductions.

Ifyourcoverageselectionrequiresmedicalunderwriting,youwillneedtocompletetheonlineMetLifeStatementofHealthForm alongwithanyotherrequiredinformation.MetLifemustapproveyourapplicationbeforecoveragecantakeeffect.

Besuretodesignateyourbeneficiariesby

accessingtheGaBreezewebsiteorcallingtheGaBreezeBenefitsCenter.Also,youcanchangeandupdateyourbeneficiariesatanytime.

Please be advised.NopaperStatementofHealthFormwillbemailedfortheemployeeand/orthespousetocomplete.Anonlinepre-registrationprocesswillneedtobecompletedforaspouserequiringmedicalunderwritingbeforetheStatementofHealthFormwill be available online.

• ForinformationregardingconversionandportabilityofyourEmployeeLife,SpouseLife,ChildLifeinsurance,andAD&Dinsurances,contactMetLife,toll-free,at1-877-255-5862.

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Short and Long-Term DisabilityTohelpprovideincomeprotectionagainsttheunexpected,theFlexibleBenefitsProgramallows youtochoose:• Short-TermDisabilityinsuranceand/or• Long-TermDisabilityinsurance.

Short-Term Disability with Standard Insurance Company

Ifyouchooseshort-termdisability(STD)coverage,theplanwillworkincoordinationwithotherincomebenefitstoreplace60%ofyourAnnualBenefitBaseRateduringtheplanyearthedisabilitybegan,upto$1,000perweek.Ifyoureceiveotherbenefits(includingbutnotlimitedtoworkers’compensation,otherdisabilityplansand/orprogramsincludingtheStateretirementsystems,earningsfromworkyouperformwhiledisabled)whichreplaceatotalof60%ormoreofyourAnnualBenefitBaseRate,theshort-termdisabilityplanwillnotpayabenefitforthisdisability.

Your Options• Seven(7)DayBenefitWaitingPeriod• Thirty(30)DayBenefitWaitingPeriod

• How STD Works A late enrollment penalty will apply for late

entrantstotheSTDplan(employeeswhodo notelectSTDwithin30daysofemployment).

YourSTDbenefitsarecalculatedontheAnnualBenefitBaseRatethatisineffectduringtheplanyearyourdisabilitybegan,lessotherincomebenefits.Forexample,ifyourfirstdayofdisabilityisDecember3,2016,yourdisabilitybenefitwillbecalculatedfromthe2016AnnualBenefitBaseRate,notyour2017AnnualBenefitBaseRate.The2016AnnualBenefitBaseRateisbasedonyour

weeklyrateofearningsineffectonOctober1,2016,oryourhiredate,ifafterthisdate.

YourSTDbenefitscancontinueuntilyourecover,cease to be disabled, or are disabled for a maximumof150calendardaysoramaximumof173calendardays(dependingonthecoveragelevelyouhavechosen).

• What Is A Late Enrollment Penalty For Late Entrants?

Anemployeechoosingcoverageforthefirsttimemorethan30daysafterbeginningemploymentis considered a late entrant. For STD late entrantswhobecomedisabledduetophysicaldisease,pregnancy,ormentaldisorderduringthe12-monthperiodafterthedateyourSTDinsurancebecomeseffective,benefitswillnotbeginuntilafteryouhavebeencontinuouslydisabledfor60days,unlessyouhavebeeninsuredforatleast12consecutivemonths.ForSTDlateentrantswhosedisabilitiesbeginafterthis12monthperiod,benefitswillstartafterthebenefitwaitingperiod(sevenor30continuouscalendardays,asapplicable)issatisfied.

Whenchangingfromthe30-dayBenefitWaitingPeriodtotheseven-dayBenefitWaitingPeriod,yourBenefitWaitingPeriodforadisabilityresultingfromphysicaldisease,pregnancy,ormentaldisorderwillbeextendedto30days,untilyouhavebeeninsuredundertheseven-dayBenefitWaitingPeriodforatleast12consecutivemonths.Thisdoesnotapply toaccidentalinjuries.

• Enrolling For Short-Term Disability Coverage Yourpremiumswillbebasedonyourage,

coveragelevel,andAnnualBenefitBaseRate.Thispremiumisapost-taxdeduction–soyouwon’tpaytaxesonthebenefitsyoureceive.

NOTE: YoushouldcheckwithyourHumanResourcesOfficeand/ormanagerconcerningleavepolicieswhendisabled.AgencypolicymayimpactyoureligibilitytoreceiveShort-TermDisabilitybenefits.

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Long-Term Disability with Standard Insurance Company

TheFlexibleBenefitsProgram’sLong-TermDisability(LTD)coverageworkswithotherbenefitsyouareeligibletoreceive,includingbutnotlimitedtoSocialSecurity,Workers’Compensation,otherdisabilityplansbenefitandprograms,includingtheStateretirementsystems.Theplanassuresthatyourcombineddisabilitybenefitsandincomefromothersourceswillequal60%ofyourAnnualBenefitBaseRateupto$5,000permonth.Thereisaminimummonthlybenefitof$100.00.

• How Long LTD Benefits May Be Payable Ifyouqualifyforbenefits,theywillbeginafter

youhavebeendisabledfor180calendardays. LTDbenefitsendwhenyouarenolongerdisabledoryoureachyourSocialSecurityNormalRetirementAge.Benefitsfordisabilitiescausedbymentaldisorders,substanceabuseandotherlimitedconditionswillnotbepaidformorethantwoyears.Ifyoubecomedisabledafterreachingage61,anage-gradedmaximumbenefitperiodwill apply.

• Enrolling For Long-Term Disability Coverage Yourcostforlong-termdisabilitycoverageisbased

onyourage,yourFICAStatus,AnnualBenefitBaseRate,andwhetherornotyouareeligiblefordisabilitycoveragethroughanyStateofGeorgiaretirementplan,and/orthroughSocialSecurity.

LTDpremiumsarepaidwithpost-taxdollars.Anybenefitsyoureceivearenotconsideredtaxableincome.

Notethatotherexclusionsandlimitationsapplytothesecoverages.RefertotheCertificatesofInsuranceformoreinformation.

Ifyouhaveanyquestionsabouteligibilityorhowtheshort-termandlong-termdisabilityinsuranceplanswork,callTheStandardat1-888-641-7186.

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Long-Term CareLong-Term Care Insurance with Unum

Long-TermCare(LTC)referstoawiderangeofpersonalcare,health,andsocialservicesforpeopleofallageswhosufferachronicdiseaseorlong-lastingdisability.Theseservicescanbeprovidedinanursingfacility,anadultdaycarecenter,orathome,andcaninvolvesomenursingcare.Thecostforthiskindofcareistypicallyveryhigh–asmuchas$20,000peryearforhomecare,andfrom$20,000to$60,000annuallyforanursinghome.Generally,youhavetopaytheseexpensesoutofyourownpocket,becausemedicalinsuranceandMedicaredonotcoverlong-term care.

• Your Long-Term Care Options Youcanchoosefromoneofthreedailybenefit

levelsandthecorrespondingmonthlypremiumthatisrightforyourneedsandbudget.Theamountofthebenefitdependsontwofactors:wherecareisprovided–eitherinanursingfacility,orhome/day/assistedlivingfacility–andthedailydollarlevelofcoverageyouselect.Withanyoftheseoptions,benefitsarepaidonamonthlybasis.Themonthlybenefitisequalto100%ofyourelecteddailybenefitamountforcareprovidedinastate-licensednursinghomefacility,and60%ofyourelecteddailybenefitamountforcare provided in an assisted living facility or at home.Ifyouwish,youcanaddareducedpaid-upoptionand/oraninflationprotectionoption.

• Who Can Be Covered Thisplanisofferedtoyou,yourspouse,your

parents,oryourparents-in-law.“Parents”arebiological(natural),adoptive,orstep-parentsofeligibleemployeesorspouses.Yourspouse,parents,andparents-in-lawwillhavetocompleteamedicalunderwritingprocessandbeapprovedforLTCcoverage.Yourfamilymembers’premiumswillbebilleddirectlybyUnum.Yourpayrolldeductionwillbeforyourindividualcoverageonly.Youcanelectspouseorfamilycoverageevenifyoudonotenroll.

• When Benefits Are Paid Benefitsbeginaftera90-dayeliminationperiod

inwhichyouoracoveredfamilymemberhasaneligiblephysicalorcognitivedisability.Youqualifyforbenefitsifthedisabilitycreatesaneedforyoutoreceivecontinualhelpfromanotherpersontocarryoutanythreeofthesixactivitiesofdailyliving:bathing,dressing,toileting,transferring,continence,andeating.Becauselong-termcarepremiumsaretakenfromyourpost-taxincome,benefitsareprovidedtax-free.

• Please note: Apre-existingconditionlimitationwillapplytocoveragepurchasedonaguaranteed-issuebasis.Itwillnotapplytocoveragethatismedicallyunderwritten.Ifapre-existingconditionlimitationapplies,andlossiscausedby,contributedto,orresultsfromapre-existingconditionpresentsixmonthsbeforetheeffectivedateofcoverage,andoccursduringthefirstsixmonthsaftercoveragebegins,nobenefitwillbepayableuntilboththesix-monthperiodandthewaitingperiodhavebeenfulfilled.

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SpecifiedIllness• About Your Premiums and Enrolling YoupayforyourLTCcoverage,throughthe

convenienceofpayrolldeduction,withpost-taxdollars.Usingpost-taxpremiumdollarspermitsthebenefitsyoureceivetobepaidtax-free.PremiumcostsarebasedonyourageasoftheBenefitCalculationDate(October1)oryourhiredate,whicheverislater.Theyoungeryouarewhenyoupurchasethiscoverage,theloweryourpremiums.Yourfamilymembers’premiumsarebasedontheirageasofthedatetheyapplyforcoverage.TheywillpaypremiumsdirectlytoUnum.

IfyouareanewemployeeandenrollinLTCinsuranceduringyourinitialenrollmentperiod,youmayselectLTCwithnomedicalunderwritingrequirements.IfyouareacurrentemployeeenrollinginLTCforthefirsttime,oranemployeecurrentlyenrolledwhowantstoincreasebenefitlevels,addoptions,orarere-enrollingafterdiscontinuingcoverage,medicalunderwritingwillberequired.Coverageforyourspouseandothereligiblefamilymemberswillbemedicallyunderwritten.

Formoreinformationaboutlong-termcarecoverage,visit www.unuminfo.com/sogorcallUnumat1-888-SOG-FLEX(1-888-764-3539).

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Critical IllnessCritical Illness Plan with Aflac/CAIC

Thegroupcriticalillnessplanhelpsyouandyourfamilycopewith,andrecoverfrom,thefinancialstressofacriticalillnessorhealthcondition.

Employee Coverage Levels$5,000 $10,000 $20,000$30,000 $40,000 $50,000 • Lump-sumbenefitsarepaiddirectlytotheinsured

followingthediagnosisofeachcoveredcriticalillnessafteryouarehospital-confinedforsaidcondition.

• Ratescannotbeindividuallyincreasedduetochangeinage,health,orindividualclaim.

• Nomedicalunderwritingisrequiredforupto$30,000incoverage,andsimplifiedmedicalunderwriting,withonlyafewhealthquestions, forhigheramounts.

• Theplanisportable,subjecttocertainstipulations,soyoumaybeabletotakeyourcoveragewithyouifyouleaveyourjob.

• Benefitswillnotreduceduetoage.

Spouse Coverage Levels$5,000 $10,000 $20,000$30,000 $40,000 $50,000

• Nomedicalunderwritingisrequiredforupto$30,000incoverage,withsimplifiedmedicalunderwriting(onlyafewhealthquestions)forhigheramounts.

• EmployeemustelectCriticalIllnessbenefitsforthespousetobeeligibleforcoverage.

• Ratesarebasedontheemployee’sage.

Child Coverage• Allyourchildren,ages0-26,arecoveredat50%of

yourbenefitamount,atnoadditionalcost.• Childbenefitsareautomaticallyincludedin

existingemployeecoverage.

Dependent Child Illnesses Covered at 100% of Maximum Benefit• CysticFibrosis• CerebralPalsy• CleftLiporCleftPalate• Down Syndrome• SpinaBifida

Covered Critical Illnesses*Illnesses Covered Percentage of Face Amount• Heartattack 100%• Stroke 100%• Majororgantransplant 100%• Renalfailure(endstage) 100%• Internalcancer 100%• Coma 100%• Severeburns 100%• Paralysis 100%• Lossofsight,hearing,orspeech 100%• Carcinomainsitu 25%• Coronaryartery 25%• AdvancedAlzheimer’sdisease 25%

* A partial benefit (25%) is payable for carcinoma in situ and coronary artery bypass surgery. Payment of the partial benefit for carcinoma in situ will reduce the benefit for internal cancer. Payment of the partial benefit for coronary artery bypass surgery will reduce the benefit for a heart attack.

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First Occurrence BenefitAfterreceiptofwrittenproofofloss,aninsuredmayreceiveupto100%ofthebenefitselecteduponthefirstdiagnosisofeachcoveredcriticalillness.

Additional Occurrence BenefitIfaninsuredindividualcollectsfullbenefitsforacriticalillnessundertheplan,andlaterhasoneoftheremainingcoveredillnesses,thefullbenefitamountforanyadditionalillnesswillbepaid.Thetwodatesofdiagnosismustbeseparatedbyatleast90days(or,forcancer,afteratleast12monthstreatment-free).Additionalcriticalillnessescannotbecaused,orcontributedto,byacriticalillnessforwhichbenefitshavealreadybeenpaid.

Re-Occurrence BenefitOncebenefitsarepaidforacriticalillness,additionalbenefitsarepayableforaneweventofthesamecriticalillness,providedthereoccurrenceisdiagnosedatleast90daysfromthedateofinitialdiagnosis.

• Cancerreoccurrence:Theinsuredmustbetreatment-freefor12monthstoreceivetheReoccurrenceBenefitforacancerdiagnosis.

• Cancerthathasspread(metastasized),evenifthereisanewtumor,willnotbeconsideredanadditionaloccurrenceunlesstheinsuredhas beentreatment-freefor12months.

Health Screening BenefitsAcoveredemployeecanreceiveamaximumof$100for any single covered screening test per calendar year.Thisbenefitispaidregardlessoftheresultsofthetestandwillnotreducetheamountpayableforthediagnosisofacriticalillness.Thereisnolimittothenumberofyearsthecoveredemployeecanreceivethehealthscreeningbenefit;itwillbepaidaslongasthepolicyremainsinforce. Thecoveredhealthscreeningtestsinclude:

• Stress test on a bicycle or treadmill• Fastingbloodglucosetest,bloodtest

fortriglyceridesorserumcholesterol testtodeterminelevelofHDLandLDL

• Bonemarrowtesting• Breastultrasound• CA15-3(bloodtestforbreastcancer)• CA125(bloodtestforovariancancer)• CEA(bloodtestforcoloncancer)• Chestx-ray• Colonoscopy• Flexiblesigmoidoscopy• Hemocultstoolanalysis• Mammography• Papsmear• PSA(bloodtestforprostatecancer)• Serumproteinelectrophoresis

(bloodtestformyeloma)• Thermography

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Critical Illness Select Plus Plan

IncludesAccidentBenefitsforyouandyourfamily intheeventofanonoroffthejobaccidentalinjury.

• Indemnitybenefitspaidastheresultofanaccidentalinjury

• 24-hourcoverage• Over50accidentindemnitybenefitsincluded• Nomedicalunderwritingrequiredupto

GuaranteedIssueamount• Ratescannotbeindividuallyincreaseddueto

changeinage,healthorindividualclaim• Theplanisportable,subjecttocertain

stipulations,soyoumaybeabletotakeyourcoveragewithyouifyouleaveyourjob

• WellnessBenefitof$60

Plan Benefits SummaryPleaserefertoyourcertificateofcoverage fordefinitions,limitationsandexclusions

BenefitsInclude:• MedicalFees(PhysicianCharges,X-Rays,

EmergencyRoomServicesandSupplies)• HospitalFees(HospitalAdmission,DailyHospital

ConfinementandIntensiveCare)• AccidentalInjuries(Fractures/Dislocations,

Lacerations,Tendons/Ligaments,RupturedDisk,TornKneeCartilage,Burns,EyeInjuries)

• AccidentFollow-upBenefits(PhysicalTherapy, In-patientRehab,Follow-uptreatments)

• AdditionalBenefits(FamilyLodging,Transportation,GunshotWound,Paralysis,Prosthesis)

For a complete list of benefits and descriptions, please refer to the Critical Illness Select Plus PDF Brochure or your certificate of coverage

Premiums for the Critical Illness coverages in this section are paid on a post-tax basis – which allows you to receive benefits tax-free

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Legal InsuranceLegal Insurance with Hyatt Legal Plans

Whetheryou’rebuyinganewhome,drawingupawill,orjustneedsomelegaladvice,theHyattLegalPlancangiveyouaccesstoexperienced,localnetworkattorneysatanaffordablerate,throughpremiumstakenonapost-taxbasis.

Legal BenefitsThelegalservicescoveredbytheplan,asdefinedbyyourSummaryPlanDescription(SPD),arefullycoveredwhenyouseeaParticipatingPlanAttorney.Youcanusetheplanasoftenasyouneedlegalrepresentation,withoutwaitingperiods,copayments,ordeductibles.

Access to Over 14,000 AttorneysTheHyattLegalPlanprovidesmemberswithaccesstoanationalnetworkofmorethan14,000PlanAttorneys.Ifyouprefer,youmayuseyourownattorneyandbereimbursedaccordingtoasetfeeschedule.IfyoufindyourselfinneedoflegalassistancewhiltetravelingwithintheU.S.,calltheHyattClientServiceCenterat800-821-6400,visit www.info.legalplans.com,ordownloadHyattLegalPlan’smobileapptolocateparticipatingattorneysinthearea.

Your Legal Benefit OptionsReviewthecoveragesbelowandonthefollowingpageandselecttheplanthatfitstheneedsofyouandyourfamily.Youcanenrollineitherplanwithsinglecoverageorcoverageforyouandyourdependents(uptoage26).

Select Plan

TheSelectoptionprovidesbenefitsforthe followingservices:

• Wills and codicils• Living wills• Powersofattorney• Unlimitedphoneandofficeadvice

andconsultations• Trafficticketdefense(noDUI)• Documentreview• Deeds• Mortgages• Promissorynotes• Elderlawmatters• Sale,purchaseandrefinancingofyour

primaryandsecondhome• Homeequityloansforyourprimary

andsecondhome• Debtcollectiondefense• Identitytheftdefense

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Select Plus Plan

TheSelectPlusoptionprovidesbenefitsforthefollowingservices:

• Wills and codicils• Living wills• Powersofattorney• Unlimitedphoneandofficeadvice

andconsultations• Probateproceedings• Consumerprotectionmatters• Debtcollectiondefense• Identitytheftdefense• Personalbankruptcy• Taxaudits• Civillitigationdefense• Administrativehearings• Incompetency defense• Changeorestablishmentofcustodyorder

orvisitationrights• Adoptionandlegitimization• Divorce*($1,000maximumforcontested)• Enforcementormodificationofsupportorder• Guardianship/conservatorship• Immigrationassistance• Trafficticketcefense(noDUI)• Sale,purchase,refinancingofyourprimaryand

secondhome• Evictionandtenantproblems(tenantonly)• Homeequityloansforprimaryandsecondhome• Namechanges

• Juvenilecourtdefense• Deeds,promissorynotes&mortgages• Documentreview• Elderlawmatters• Securitydepositassistance(tenant)• Protectionfromdomesticviolence

TheSelectPlusoptionoffersthesameservicesastheSelectPlan,plusadditionalservicesinfamilylaw,debtmatters,consumerprotection,tenantmatters,immigration,andcivillitigationdefense.

What Are the Exclusions?Thelegalplanexcludesappeals;classactionsandappeals;mattersthatHyattLegalPlansdeemfrivolous,non-meritorious,orunethical;farmandbusinessmatters;patent,trademark,andcopyrightmatters;costsandfines;mattersforwhichanattorney-clientrelationshipexistpriortoyourbecomingeligibleforplanbenefits,andanyemployment-relatedmatters.Foracompletelistofexclusions,visitwww.GaBreeze.ga.gov.

What if I have More Questions?Call1-800-821-6400MondaythroughFridayfrom8a.m.to7p.m.(EasternTime).AClientServiceRepresentativewillhelpyouunderstandcoverage,findaplanattorneyinthelocationmostconvenienttoyou,offerinformationaboutusinganout-of-networkattorney,andansweranyotherquestions.

Formoreinformation,downloadHyatt’smobileapporvisitthewebsitewww.info.legalplans.com. Enter theappropriateaccesscode,asfollows:

Select Plan7600001-EmployeeOnly7610001-Employeew/Dependents

Select Plus Plan7620001-EmployeeOnly7630001-Employeew/Dependents

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Spending AccountsTheSpendingAccountplansareadministeredbyADP.

Forthe2017planyear,theannualamountsyou maycontributeare: Minimum Maximum DependentCare $120 $4,960HealthCare $120 $2,510

TheIRSrulesandtherulesoftheEmployeeBenefitsPlanCouncildesignateeligibleexpenses.TheEmployeeBenefitsPlanCouncilhastheresponsibilitytointerprettheserulesandmakealldecisionsastoanexpense’seligibility.

Important Information About Spending Accounts• Deductionsforspendingaccountsaremadeona

pre-taxbasiseverypayperiod.• Yourspendingaccountelectionsarebindingfor

theplanyear.Youmaybeabletomakelimitedchangesifyouhaveaqualifiedstatuschange.

• Youcannotcarryoverexpensesthatyouhaveincurredinoneplanyearintothenextplanyearforreimbursement.

• Youcannottransfermoneyfromoneaccount toanother.

• Claimsshouldbesubmittedonlyafterserviceshavebeenprovided.

• Youmaysubmitclaimsatanytimeforanyamount,butpaymentwillnotbemadeuntil yourclaimstotal$25ormore.Reimbursementmaybebycheckorbydirectdeposittoyourbankaccount.

• Duringtheyear,youreceivestatementsshowinghowmuchyouhaveineachaccount.

• Reimbursementsareissuedonadailybasis.• UnderIRSrules,anymoneyleftinyour

accounts,andnotclaimedforthepreviousplanyear’sexpensesbytheclaimfilingdeadline,isforfeited.Itisretainedbytheplanandusedforadministrativeexpenses.

TheHealthCareSpendingAccounthasagraceperiodthatcanhelpyouavoidlosingmoneyforunclaimedexpenses.Seepage31.

• Amonthlyadministrationfeeof$3.20isincludedinthetotalcontributionamountfortheHealthCareSpendingAccount.

Important Note:Pleasebeawarethatifyouarecurrentlycontributingtoaspendingaccount,yourannualallocationwillnotautomaticallycontinueintothenewplanyear.Youmustmakeanewelectionifyouwanttocontributetotheplansin2017.

ContactGaBreezeBenefitsCenterat1-877-342-7339formoreinformation.

Dependent Care Spending Account (DCSA)

TheDependentCareSpendingAccountprovidesyouwiththeopportunitytousetax-freedollarstopayforthecareofyourchildrenunderage13orotherIRS-eligibledependents(suchasadisabledchildofanyageoranelderlyparent)whileyouandyourspouseworkorattendschoolfulltime.

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Eligiblechildcareservicesmayincludeyourcosttosendachildtopreschool,afterschool,ornurseryschool.Also,expensesfordependentsofanyagewhoareunabletocareforthemselvesbecauseofaphysicalormentalhandicapareeligible.Apersonqualifyingforthistypeofcaremustspendatleasteighthoursadayinyourhome.Elderlydependentcaremayincludeyourcosttosendadependentparenttoaneldercarefacilityorhavesomeonecarefortheminyourhome.

Ifyouaremarried,bothyouandyourspousemustbeworking,orbeafull-timestudent,duringthetimethecareisreceived.Yourincometaxreturn(longandshortforms)willrequireyoutoincludeyourdependentcareprovider’snameandtaxnumberorSocialSecuritynumber.

Dependent Care Spending Account Exclusions ListTheseareafewexamplesofdependentcareexpensesthatarenoteligibleforreimbursement.• Activityandbookfees• Cleaningandcookingservicesnotprovided

bythecareprovider• Field trips• Food,clothing,andentertainment• Kindergarten• Overnightcamps• Sports lessons

• Transportationtoandfromthechildcareprovider• Tuitionforprivateschool

NOTE:YoushouldcarefullyreviewyouroptionsandconsultaqualifiedtaxadvisorforassistanceindeterminingusingtheDependentCareTaxCreditorusingtheDependentCareSpendingAccount.

Dependent Care Spending Account LimitsYoumaynotbeabletodepositthefull$4,992ifanyofthefollowingsituationsapplytoyou.• IfyourspouseworksfortheState,oranother

employerwhooffersasimilarplan,thetotalofyourfamily'scontributionstoadependentcarespendingaccountcannotexceed$4,992.

• Ifeitheryouoryourspouseearnslessthan$5,000ayear,youcandepositasmuchasthesmallerofyourtwoincomes.

• Ifyourspouseiseitherafull-timestudentorincapableofself-care,youmaydepositupto$3,000foronedependent,or$4,992fortwoormore dependents.

• Ifyouaremarriedbutfileaseparatefederalincometaxreturn,youmaydepositamaximumof$2,500toyourdependentcarespendingaccount.

• IfyouarehiredafterJanuary1,orhaveaqualifiedchangeinstatusduringtheplanyear(seeTermsandConditions),youmaycontributeupto$416permonthfortheremainderoftheplanyear.

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Health Care Spending Account (HCSA)

TheHealthCareSpendingAccount(HCSA)helpsyousavetaxdollarsonhealth-relatedproductsandservicesreceivedbyyouandyourfamily.

Debit CardWhenyouenrollinaHealthCareSpendingAccount,you’llreceiveaVISA®SpendingAccountCardforpurchasesofeligiblehealthcareservices.Thiscardwillarrivefundedwithyourfull annual allocation. Youmayrequestuptofouradditionalcardswithyourspouseordependent’snameonit,forafeeof$5percard.Ifyourcardislostorstolen,youmayrequestanothercardforafeeof$15.Foradditionalcards,callADPat1-800-893-0763.

Keeping ReceiptsRemember,youmustkeepyourreceiptssincesometransactionsmayrequirevalidationbyADP.

Important Note: TheIRSdoesnotallowparticipationinbothHealthCareSpendingAccountsandHealthSavingsAccounts.

Examples of Eligible Expenses• Deductiblesandco-paymentsnotpaid

byanyhealthordentalinsuranceinwhichyouoryourfamilymembersparticipate

• Costsforproceduresnotcoveredor notcoveredfullybyahealth,dental, or vision plan

• Specializedequipmentfor disabled persons

• Preventativecarescreenings• Contact lens and glasses• Lasereyesurgery• Prescription• Mentalhealthservices• Physicaltherapy• CertainotherIRSapprovedexpenses

Examples of Ineligible Expenses • Cosmeticprocedures/drugs• Electrolysis• Hairtransplants• Herbalsupplements• Insurancepremiums• Nicotinepatchesandgum• Nutritionalsupplements• Teethwhitening/bonding• Vitamins• Over-the-countermedications

HCSA Grace Period of 2½ Months

UndertheHCSA,theIRSallowsyouagraceperiodtoavoidthe“UseItorLoseIt”provision.IfyouhaveanyHCSAfundsremainingonDecember31,youhaveanadditional2½months–throughMarch15ofthefollowingyear–todepleteyouraccount.Youcancontinuetouseyourdebitcard,orsubmitqualifiedexpensesforreimbursement,forproductsandservicespurchasedthroughMarch15th.You’llhaveuntilApril30thtosubmitsuchclaimstoADP.Remember,ifaclaimismailed,theenvelopemust bepostmarkedbyApril30th.Thefastestwayto getclaimstoADPistofaxthemat1-866-643-2219.

Tobesttakeadvantageofthisgraceperiod,fund onlythoseexpensesyouexpecttohaveduring the12-monthperiod.Ifyoudonotspendallof themoneyyoucontributed,duringtheplanyear, besuretouseitupduringthegraceperiod.

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EMPLOYEE CHECKLISTReview YOU DECIDEforvaluableinformationfor

eachoption,descriptionsofrequiredmedicalunderwritingrequirements,andTermsandConditions.

EnsureyouhaveyourIDandpasswordfortheGaBreeze website.

Checkwithyourentity'sHumanResources/PayrollOfficeforapplicabledeadlines.

ConfirmontheGaBreezewebsitetoseeifadditionaldocumentationrequired,suchasmedicalunderwritingforms.

ReviewyourConfirmationPageandreportdiscrepanciesimmediatelytoGaBreezeBenefitsCenter1-877-342-1339.Followuptoensurethatcorrectionsaremade.

Compareyourpaystub(s)againsttheoptionsyouselected.Contactyourpersonnel/payrollofficeifyoufindanydiscrepancies.

Reportanyincorrectinformationtoyourpersonnel/payrolloffice.

Additional Information

TheFlexibleBenefitsProgramattemptstobeasconsistentaspossiblewithStateHealthBenefitPlanrulesandregulations.Thisisnotalwayspossibleduetothevariationsinbenefitofferings.

ThisbookletsummarizesthebenefitsyoucanchoosethroughtheStateofGeorgiaFlexibleBenefitsProgram.AmoredetailedexplanationofbenefitprovisionsisprovidedineachBenefitSummaryPlanDescription.Everyattempthasbeenmadetoensurethattheinformationinthisbookletisaccurate.

TheStateofGeorgiaFlexibleBenefitsProgramisgovernedbylegaldocumentationandinsurancecontracts.However,intheeventthereareanyconflictsbetweenthisbookletandtheofficialplandescriptionsandcontracts,thetermsoftheofficialplandescriptionsandcontractswillprevail.

TheFlexibleBenefitsProgramisgovernedbycurrenttaxlawandissubjectto,andoperatedinaccordancewith,regulationsoftheInternalRevenueService(IRS).IfchangesintheFlexibleBenefitsProgramarenecessary,wewillmakeupdatestocomplywithappicableIRSregulations.

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HIPAA PRIVACY AND SECURITY NOTICETheHealthInsurancePortabilityandAccountabilityActof1996(HIPAA)requiresthatcoveredentities,includingstateagenciesthatdealwithProtectedHealthInformation(PHI),provideyouwiththisnoticeregardingprogramsadministeredbytheDepartmentofAdministrativeServices(DOAS)inwhichDOASmaymaintainvarioustypesofPHIaboutyou.DOASunderstandsthatinformationaboutyouandyourfamilyispersonal.Assuch,DOASiscommittedtosecuringandprotectingyourconfidentiality.

Thisnoticetellsyou(a)howDOASusesanddisclosesinformationaboutyouand,(b)discussesyourrightsinkeepingthisinformationprivateandsecure.Pleasereviewthisnoticecarefully.

Overview

What is HIPAA?HIPAA,theHealthInsurancePortabilityandAccountabilityActof1996,isafederallawregardingtheconfidentialityandsecurityofProtectedHealthInformation(PHI).Itimposesrestrictionsonhowyourhealthinformationcanbeusedandshared,andconfirmsrightsforindividualsconcerningtheirhealthinformation.

What is PHI?PHI,ProtectedHealthInformation,isindividuallyidentifiablehealthinformationthatismaintainedortransmittedbyacoveredentity.Itisinformationrelatedtoaperson’shealth,provisionofcare,orpayment.ExamplesofitemscontainingPHIincludeabillforhealthservices,anexplanationofbenefitsstatement,receiptsforreimbursementfromahealth

carespendingaccount,oranylistshowingtheamountofbenefitspaidwithabreakdownbysocialsecuritynumber.Thisalsoincludesyouremployer(e.g.,stateagency,schoolsystem,authority)transmittinginformationaboutyoutoDOAS.Thisinformationmayincludeyourname,address,birthdate,socialsecuritynumber,employeeidentificationnumber,andcertainhealthinformation

How DOAS Uses and Discloses Protected Health InformationWhenservicesarecontracted,DOASmaydisclosesomeorallofyourinformationtothecompanytoperformthejobDOAShascontractedwiththemtodo.DOASrequiresthecompanytosafeguardyourinformationinaccordancewithfederalandstatelaw.

Privacy and Security Law RequirementsDOASisrequiredbylawto:• Maintaintheprivacyofyourinformation.• ProtectelectronicPHIbyimplementingreasonable

andappropriatephysicaladministrativeandtechnicalsafeguards.

• ProvidethisnoticeofDOAS’legaldutiesandprivacyandsecuritypracticesregardingtheinformationthatDOAShasaboutyou.

• Abidebythetermsofthisnotice.• Refrainfromusingordisclosinganyinformation

aboutyouwithoutyourwrittenpermission,exceptforthereasonsgiveninthisnotice.Youmayrevokeyourpermissionatanytime,inwriting.ThatrevocationwillnotapplytoinformationthatDOASdisclosedpriortoreceivingyourwrittenrequest.Ifyouareunabletogiveyourpermissionduetoanemergency,DOASmayreleaseinformation,ifitisinyourbestinterest.DOASmustnotifyyouassoonaspossibleafterreleasingtheinformation.

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Your Health Information RightsYouhavethefollowingrightsregardingthehealthinformationmaintainedbyDOASaboutyou:• Seeandobtainacopyofyourhealthinformation.

ThisrightwouldnotextendtoinformationneededforalegalactionrelatingtoDOAS.

• AskDOAStochangehealthinformationthatisincorrectorincomplete.DOASmaydenyyourrequestundercertaincircumstancesorrequestadditionaldocumentation.

• RequestalistofthedisclosuresthatDOAShasmadeofyourhealthinformationbeginninginApril2003.

• Requestarestrictiononcertainusesordisclosuresofyourhealthinformation.DOASisnotrequiredtoagreewithyourrequest.

• RequestthatDOAScommunicatewithyouaboutyourhealthinawayoratalocationthatwillhelpyoukeepyourinformationconfidential.

• RequestanothercopyofthisnoticefromDOAS,oryoumayobtainacopyfromtheDOASwebsite,www.doas.ga.gov(under“Privacy”).

For More Information and To Report a ProblemIfyouhavequestionsandwouldlikeadditionalinformationaboutProtectedHealthInformation(PHI)youmaycontactGaBreezeat1-877-342-7339MondaythruFriday8:00a.m.to5:00p.m.Youmayalso visit DOAS web site, www.doas.ga.gov.

DOASdoesnotdiscriminateonthebasisofdisabilityintheadmissionoraccessto,ortreatmentofemploymentinitsprogramsoractivities.IfyouhaveadisabilityandneedadditionalaccommodationstoparticipateinanyDOASprograms,pleasecontacttheDOASatthenumberslisted.ForTDDrelayserviceonly:1-800-255-0056(text-telephone)or1-800-255-0135(voice).

Ifyoubelieveyourprivacyorsecurityrightshavebeenviolated:• Youmayfileacomplaintinwritingtothe

DOASPrivacyUnitat: Department of Administrative Services

Attn: Privacy Officer 200 Piedmont Avenue SE West Tower, Suite 502 Atlanta, GA 30334-9010

• YoucanfileacomplaintwiththeSecretaryofHealthandHumanServicesbywritingto:SecretaryofHealthandHumanServices,200IndependenceAve.SW,Washington,DC20201.Foradditionalinformation,call1-877-696-6775.

• YoumayfileagrievancewiththeUnitedStatesOfficeforCivilRightsbycalling1-866-OCR-PRIV(1-866-627-7748)or1-886-788-4989TTY.

Therewillbenoretaliationforfilingacomplaintorgrievance.

IfDOASchangesitsprivacyorsecuritypracticessignificantly,DOASwillpostthenewnoticeonitsweb site at www.doas.ga.gov.

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BENEFIT PLANS PHONE DIRECTORY

GaBreezeBenefitsCenterWebsite:www.GaBreeze.ga.gov

Phone:1-877-342-7339

Benefit Type Name & Contact Information

Dental Insurance CIGNA 1-800-642-5810 www.cigna.com

Delta–SelectandSelectPlus 1-866-496-2384 www.deltadentalins.com

Vision Coverage BlueCrossBlueShield 1-855-556-4844 www.bcbsga.com

Employee, Spouse, Child Life Insurance MetLife and Accidental Death and Dismemberment 1-877-255-5862 www.mybenefits.metlife.com

Disability Insurance TheStandard 1-888-641-7186 www.standard.com

Long-Term Care Insurance Unum 1-888-SOG-FLEX(1-888-764-3539) www.unum.com

Critical Illness Insurance Aflac 1-800-433-3036 www.aflacgroupinsurance.com

Legal Insurance HyattLegalPlans 1-800-821-6400 www.legalplans.com

Spending Accounts ADP–GaBreeze 1-800-893-0763 www.myspendingaccount.adp.com

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TERMS AND CONDITIONSTheFlexibleBenefitsProgramisofferedbytheEmployeeBenefitsPlanCouncilandparticipatingdepartmentsandauthorities.TheFlexibleBenefitsProgramisgovernedbytheInternalRevenueCode,section125,andrulesissuedbytheEmployeeBenefitsPlanCouncil.TheFlexibleBenefitsProgramprovidesyouwithamethodtohaveyouremployerpurchasebenefitswithmoneythatwouldhavebeenpaidtoyou.Youdonotreceivethepremiumamountsandcontributionsforthepre-taxoptionsyouselectastaxableincome(andthereforedonotpaytaxesonthatamount);youdoreceivethebenefitsasanemployerpaidbenefit.Theelectionisabindingsalaryagreement.FailuretocomplywithallcontractualandadministrativerequirementswillresultinanyexcesssalaryreductionsbeingretainedbythePlan.ThefollowingstatementsapplytothebenefitoptionslistedontheAnnualEnrollment web site.

1) YourparticipationintheFlexibleBenefitsProgramisvoluntary.Youarenotrequiredtochooseanyoftheoptions.Ifyoudonotwishtoparticipateinthesebenefits,select‘nocoverage’ineachbenefitcategory.

2) Somecoveragelevelsavailabletoyouandthepremiumamountforeachcoveragelevelmaybecalculatedusingyourretirementsalary,yourage,youreligibilityfordisabilityretirementbenefits,andFICAstatusonyourdateofhireortheBenefitCalculationDate,whicheverisdeemedappropriatebythePlanAdministrator.AnyadjustmentstotheAnnualBenefitBaseRate,withtheexceptionoferrors(asdeterminedbythePlanAdministratorshallbereflectedonthefollowingBenefitCalculationDate,tobeeffectiveforthefollowingplanyear.)Promotions,demotions,adjustmentsduetocertificationsarenotdeemedtobeerrors.Anyerrorsintheseitemsshouldbereportedtoyourpersonnelorpayrollofficeimmediately.

3) Thecalculationoftaxsavingsdoesnottakeintoconsiderationanyotherincomeearnedbyemployeeorfamilymembers,incomereductionprogramsuchasDeferredCompensationorTaxShelteredAnnuities,oranychangesyoumaymakeincoveragesfortheupcomingyear.

4) ByselectingcoveragesandindicatingcontributionstoSpendingAccounts,youareagreeingthatyouragencymayreduceyourtaxableincomebytheamountnecessarytopurchasethosecoveragesandmakethosecontributions.Exceptincertaincircumstances,theamountofincomereductionmaynotbechangeduntilthenextenrollmentperiod.

5) Fordependentand/orspousalcoverage,itisyourresponsibilitytonotifytheGaBreezeBenefitCenterifthepersonceasestobeeligibletoparticipateinthePlan.TherewillbenorefundofpremiumspaidintothePlan,whenatimelychangeisnotmade.

6) AfterthisenrollmentperiodyoumaybecomeaparticipantormakechangesinsomecoveragesonlyunderlimitedconditionsinaccordancewiththerulesoftheIRScode,theEmployeeBenefitsPlanCouncil.TheEmployeeBenefitsPlanCouncilhastheresponsibilitytointerprettheserulesandmakethefinaldecisionastowhetheryoumayenrollorchangeanycoverageoutsideoftheenrollmentperiod.Yourrequestforenrollmentorachangeoutsideoftheenrollmentperiodwillonlybeconsideredifyousubmittheproperdocumentationwithinthetimeframeallotted.

YourrequestforenrollmentorachangeincoverageundertheFlexibleBenefitsProgrammustbedonebycallingtheGaBreezeBenefitCenteroronthewebsitewithin30days.AlistofeventsthatmightpermityoutoenrollorchangeoneormorecoveragesundertheFlexibleBenefitsProgram:a) Yougainorloseaspouse;orb) Yougain(notimelimitifduetojudgment,decree

ororder)orloseaneligibledependent;orc) Yourspouseordependentbecomeseligiblefororloses

coverageunderanotheremployer’splan,COBRAoragovernmentalplan;or

d)Aneventcausesyourdependenttogainorloseeligibilityforcoverageunderyouremployer’splan;or

e) Yourchangeofresidencecausesyouoryourspouseordependentstogainorloseeligibilityforcoverageunderyourplanoranotheremployer’splan;or

f) Thecostofyourdependentcareincreasesordecreasessignificantlyandyourdependentproviderisnotrelatedtoyou,yourspouse,oryourdependent;or

g)Yourspouse’semployerincreases,decreasesorceasescoverage,orconductsopenenrollment.

7) Thissalaryagreementwillbeterminatedifyouchangetheagreementduringthenextenrollmentperiod.Ifyoudonotchangetheagreement,yourbenefitchoiceswillrolloverinthenextPlanyearordefaulttoaspecifiedcoveragewiththeexceptionoftheFlexibleSpendingAccounts.

8) IfyouareeligibletoparticipateinthePlan,youterminateandarerehiredwithin30daysduringthesameplanyear,youmustmaintainthesameoptions.

9) OptionsandcoverageundertheFlexibleSpendingAccountsaresetforthintheFlexibleBenefitPlanDocument.ForallotherbenefitsundertheFlexibleBenefitsProgram,theoptionsandcoveragelevelsofferedconformtopoliciesprovidedbytheinsurancecompanymakingtheoffer.Byselectinganoptionandcoveragelevelyouagreetoabidebythetermsandconditionsofthatpolicy.

10) ContributionstoSpendingAccountsarevoluntary.YoushouldnotparticipateinSpendingAccountsuntilyouthoroughlyreadthesectionsoftheEnrollmentBookletrelatedtoSpendingAccounts.BychoosingtocontributemoneytooneormoreSpendingAccountsyouareagreeingtoabidebytheRulesoftheEmployeeBenefitsPlanCouncilrelatedtoSpendingAccounts.Inparticular,youareagreeingtothefollowingprovisions:a) MoneycontributedtotheHealthCareSpendingAccount

cannotbeusedtopayclaimsfortheDependentCareexpenses.MoneycontributedtotheDependentCareSpendingAccountcannotbeusedtopayclaimsfortheHealthCareexpenses.

b)Ingeneral,theamountcontributedforaDependentCareAccountcannotbegreaterthantheearnedsalaryofyouoryourspouse,whicheverisless.

c)Ifyouaremarriedfilingseparately,theamountcontributedforaDependentCareAccountcannotbegreaterthan$2,500.

d)ThevalidityofaclaimagainstaSpendingAccountisdeterminedinaccordancewiththePlan,InternalRevenueCode,andIRSregulationsasinterpretedbytheAdministratorsubjecttotheappealprovisionsofthePlan.

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e)AnymoneynotreimbursabletoyouwillbeforfeitedtotheFlexibleBenefitsProgram.Forfeitedmoneywillnotbereturnedorpaidtotheemployeebutwillbeusedtoreducethecostsassociatedwithprovidingthisbenefit.NOTE:Thisruleisintendedtoensureyouallocateonlythoseexpensesyouexpecttoincur.Seep.31forinformationaboutthegraceperiodthatcanhelpyouavoidhavingtoforfeitHealthCareSpendingAccountfunds.

f) FortheSpendingAccounts,eligibleexpenseswillbereimbursedinaccordancewiththeRulesoftheEmployeeBenefitsPlanCouncilandtheIRScode.

g)FortheDependentCareSpendingAccount,youwillnotbereimbursedformorethanthePlanhasreceivedfromyourdepartmentonyourbehalf.

h)IfyoudecidetoactivateandusetheSpendingAccountdebitcard,youagreetoabidebyallrequirementsasindicatedinthecardholder’sagreementreceivedwiththecard.

11) ByselectingtheCriticalIllnessBenefit,youareagreeingtothefollowing:a)Iamassertingthattothebestofmyknowledgeandbelief,

theanswerstothequestionsontheapplicationaretrueandcomplete.TheyareofferedtoContinentalAmericanInsuranceCompanyasthebasisforanyinsuranceissued.ItisunderstoodandagreedthatcoveragewillnotbecomeeffectiveunlessIamactivelyatworkonthedateofenrollmentandtheeffectivedateofcoverage.

b)Iunderstandandagreethatnobenefitsarepayableforlossstartingoroccurringwithin12monthsoftheeffectivedateofcoveragewhichiscausedby,contributedtoby,duetoorresultingfromaPre-existingcondition,unlessIhavegone12monthswithoutmedicalcare,treatmentorsuppliesforthePre-existingcondition.

c) Irealizethatanyfalsestatementormisrepresentationmayresultinlossofcoverageunderthecertificate.Iunderstand

thatnoinsurancewillbeineffectuntilapprovedbyContinentalAmericanInsuranceCompanyandthenecessarypremiumispaid.Anypersonwho,withintenttodefraudorknowingthatheisfacilitatingfraudagainstaninsurer,submitsanapplicationorfilesaclaimcontainingafalseordeceptivestatementmaybeguiltyofinsurancefraud.

d)IauthorizemyemployertodeducttheappropriateamountfrommyearningsandtodeductandpayContinentalAmericanInsuranceCompanythepremiumrequiredthereaftereachmonthformyinsurance.

12) Othertermsandconditions:a)Ifyouchoosenottoparticipateorchoosenottocontinue

coverages,yourabilitytoenrollatalaterdatewillbesubjecttocontractualprovisions,whichmayincludemedicalproofofinsurabilityorlimitedcoverages.

b)Ifyoufailedtoenrollinoptionsrequiringmedicalunderwritingwhenfirsteligibleandyouchooseneworincreasedlevelsofcoverage,youmustcompletethemedicalunderwritingprocess and be approved.

c)IfyouchoosecoverageundertheLifeInsuranceoptionsandtheAccidentalDeathandDismembermentoptions,thesameBeneficiaryelectioninformationwillbeused.Ifabeneficiaryisnotnamed,thebeneficiarywillfollowtheorderstatedinthepolicy.

d) Ifyouselectmorethan$50,000undertheLifeInsuranceoption,youmaychoosetopaythepremiumwithpost-taxdollarstoavoidhavingtopayimputedincome;thiswilleliminateanytaxsavingsonthelifeinsurancepremium.

13) IntheeventofanadministrativeerrorwithrespecttotheFlexibleBenefitsProgram,decisionswillbemadeinaccordancewiththeInternalRevenueCode,andtheRulesoftheEmployeeBenefitPlanCouncilfortheFlexibleBenefitsProgram.