Welcome to Montefiores Benefits Program For Your Benefit

Welcome to Montefiore’s Benefits Program!

For Your Benefit

Montefiore’s Benefits Program • Healthcare • Flexible Spending Accounts • Life & Accident Insurance • Disability

Who Is Eligible? • Your Family Members – Spouse – Children – up through age 26

Healthcare • Medical • Vision • Dental

Medical • Monte. Care EPO • Monte. Care PPO • Decline Coverage • You & Montefiore share the premium cost of coverage

Provider Network Coverage MONTECARE EPO MONTECARE PPO In-network Only In-network/Out-of-network In-network Providers • Hospitals and Other Facilities Empire Blue. Card PPO and Montefiore Network (including Moses, Weiler, Wakefield, Westchester Square, The Children’s Hospital at Montefiore, Montefiore Mount Vernon Hospital, Montefiore New Rochelle Hospital, White Plains Hospital, Montefiore Ambulatory Surgical Facilities, Montefiore Imaging Center, Montefiore Department of Radiology, Advanced Endoscopy Center and NY GI Center) • Physicians, Therapists and Counseling for Mental Health and Substance Abuse • Montefiore Integrated Provider Association (MIPA) • Montefiore Behavioral Care Integrated Provider Association (MBCIPA) • Empire Blue. Card PPO Network • Empire Behavioral Health Network • Laboratories Quest Laboratories, Lab. Corp and any hospital laboratory participating in the Empire Blue. Card PPO and Montefiore Network (including Moses, Weiler, Wakefield, Westchester Square, The Children’s Hospital at Montefiore, Montefiore Mount Vernon Hospital, Montefiore New Rochelle Hospital, White Plains Hospital)

Your Share of the Cost - Individual/Family Deductible Individual/Family Out-of-pocket Maximum Physician (Primary Care or Specialist) MONTECARE EPO MONTECARE PPO Montefiore Network Empire Blue. Card PPO Network Out-ofnetwork Montefiore Network Empire Blue. Card PPO Network Out-of-network None $500/$1, 000 Not covered None $200/$400 $1, 000/$2, 500 $5, 350/$10, 700 Not covered $5, 350/$10, 700 $6, 000/$17, 500 $15 copay/visit 20%* Not covered $15 copay/visit 10%* 30%* Hospital – Pre-certified $0 20%* Not covered; except in an emergency $0 $1, 000 copay 30%* after $1, 000 copay Outpatient Surgery $0 20%* Not covered $0 $500 copay 30%* MRI, MRA, CAT Scan, PET or Nuclear Cardiology $0 20%* Not covered $0 $250 copay 30%* $100 copay $100 copay Emergency Room (copay waived if admitted) * after deductible

Prescription Drugs Generic Preferred (Formulary) Non-preferred (Non-formulary) • 30 -day supply* $0 $20 copay You pay 100% of the discounted cost $20 copay • 90 -day supply** $0 $40 copay You pay 100% of the discounted cost $40 copay $15 copay $45 copay You pay 100% of the discounted cost $100 copay o 30 -day supply* $15 copay $45 copay You pay 100% of the discounted cost $100 copay o 90 -day supply** $30 copay $90 copay You pay 100% of the discounted cost $150 copay Specialty Montefiore Outpatient Pharmacies Express Scripts • Participating Retail Pharmacy (up to a 30 -day supply ) • Home Delivery Pharmacy Service * new prescriptions for chronic and seasonal allergy medications ** refills and all other prescriptions

Care Guidance • Health & Lifestyle Assistance – Recovering from illness/injury – Managing chronic condition – Transitioning from inpatient care • Voluntary, Confidential, Free

Vision • Spectera Vision Plan – Low Option – High Option – You pay 100% of the premium cost • Empire Blue. Cross Blue. Shield o Special. Offers

Dental DHMO Preventive & Diagnostic DPPO Dentists Use DHMO dentist Use any dentist Individual Annual Deductible None $100 (does not apply to Preventive Care) Annual Maximum Benefits (for each covered person) None $1, 500/$2, 500 if you use a Montefiore dentist Preventive and Diagnostic Services $0 $0 $0 Basic Services $0 Not covered 20%1 coinsurance after deductible Major Services 30%1 coinsurance Not covered 50%1 coinsurance after deductible Orthodontics 50%1 coinsurance Not covered 20%1 coinsurance after deductible Lifetime Orthodontic Maximum None $2, 000 1 Based on DPPO contracted fee schedules

Dental • First year, you pay 100% of the premium cost • After 1 year - Cigna DHMO – You pay 100% of the premium cost - Preventive & Diagnostic – Montefiore pays 100% of the premium cost - DPPO – You and Montefiore share the premium cost

Flexible Spending Account • Before-tax Contributions • Pay Eligible Expenses from Account • No Taxes on Withdrawals • You Save What You Don’t Pay in Taxes

Healthcare FSA • Eligible Expenses – Deductibles, coinsurance, copayments – Amounts above R & C limits – Healthcare expenses for which you pay part or all of the cost • Ineligible Expenses – Cosmetic surgery – Electrolysis – Teeth whitening

Dependent Care FSA • Eligible Expenses – Day care in or outside your home – Before/After school care, Pre-school, Nursery school – Summer Day Camp • Ineligible Expenses – Household services – Institutional Care – Overnight summer camp – Weekend or “evening out” babysitting

FSA Accounts • Maximum Annual Contribution – $2, 550 Healthcare Account – $5, 000 Dependent Care Account • Forfeit Unused Amounts • Healthcare Debit Card Convenience • Pay Me Back Claim Forms

Life Insurance • Basic – 1 X Salary (up to $250, 000) or $50, 000 (Opt Down) – After 1 year Montefiore pays 100% of the premium cost • Supplemental – 1 X – 7 X Salary (up to $750, 000) – Evidence of Insurability – You pay 100% of the premium cost • Business Travel Accident o Montefiore pays 100% of the premium cost

AD&D • Basic o 1 X Salary (up to $250, 000) § After 1 year Montefiore pays 100% of the premium cost • Supplemental o 1 X – 7 X Salary (up to $750, 000) § You pay 100% of the premium cost

Dependent Life Insurance • Option 1 – $10, 000 for your spouse – $5, 000 for each child • Option 2 – $20, 000 for your spouse – $10, 000 for each child • You pay 100% of the premium cost

Short-term Disability • Paid Sick Leave – accrued sick time o 100% base salary • New York State Disability o 50% base salary, $170/week maximum • Montefiore Supplementary Sick Pay o 2/ 3 base salary, maximum weekly benefits apply

Long-term Disability • Mandatory Basic LTD – 60% predisability earnings – Maximum monthly benefits based on position • You pay 100% of the premium cost

Buy-up LTD For Executives/Faculty Annual Salary Threshold Maximum Monthly Basic LTD Benefit $120, 000 $6, 000/month Maximum Monthly Basic and Buy-up LTD Benefit $6, 000/month Basic $9, 000/month Buy-up $15, 000/month Exempt/Non-Exempt $60, 000 $3, 000/month Combined $3, 000/month Basic $2, 000/month Buy-up $5, 000/month Combined

Group Legal Services • You pay 100% of the premium cost • Network of Participating Attorneys • Legal Services o Consumer protection o Estate planning o Family law o Real estate

Commuter Benefits • Mass Transit – Buses, Subways, Commuter Railroads, Ferry Boats, Van pool • Parking

www. My. Monte. Benefits. com

www. Monte. Benefits. com or 888. 860. 6166

What happens if I don’t enroll? • Monte. Care EPO – Single coverage • Preventive & Diagnostic Dental Care – Single coverage • Basic Life and AD&D Insurance • Mandatory Basic LTD

Welcome to Montefiore’s Benefits Program!