RFP_HUM260527_Employee_Health_Clinic_Services_and_Administration_-_Exhibit_F_-_FY_26_Benefits_Booklet.pdf

EMPLOYEE BENEFIT GUIDE

This document is designed to provide basic information regarding benefit plans and programs available to eligible employees. This document merely summarizes the employee benefit plans and programs and does not detail all of the terms, conditions, restrictions, and exclusions contained in the plan documents, carrier contracts and/or Summary Plan Descriptions (SPD) (the “plan documentation”) for the various benefit plans and programs. Every reasonable effort has been made to ensure the accuracy of the information contained in this document; however, in the event of a discrepancy between the information in this document and the plan documentation, the provisions described in the plan documentation will govern. This document does not create any contractual rights for any current or former employee, or for any other individual. The provisions of the applicable plan documentation will govern the determination of any individual’s rights under any employee benefit plan or program. Your employer reserves the right to amend or terminate any of its employee benefit plans and programs at any time and without notice or cause.

October 1, 2025 through September 30, 2026

City of Ocala

2Welcome | Annual Open Enrollment | What’s New

3Who we Cover | Qualified Life Events

4-5How to Enroll

6-7Medical Insurance Terms

8Health Risk Assessment – Wellness Incentive

9-10Medical Insurance

11Elect Rx

12Where To Go When Seeking Medical Attention

13-16Employee Health and Wellness Center | Wellness Platform

17Cost Saving Tools

18Flexible Spending Account (FSA)

19-20Dental Insurance

21Vision Insurance

22-24Basic and Voluntary Life/ AD&D Insurance

25-26Short- and Long-Term Disability Insurance

27-28Employee Assistance Program (EAP)

29Legal/ IdShield

30-31Supplemental Insurance

32-33Pet Insurance

34-43Important Notices

44Who to Call

TABLE OF CONTENTS

ANNUAL OPEN ENROLLMENT

During the annual open enrollment period, you may make changes to your benefit plan elections and/or the family members you cover. Changes can only be made outside of the annual enrollment period if you experience a qualified life event. Now is the time to carefully review your plan options. Open Enrollment for our benefit plans will be conducted July 16th through August 1st. Elections you make during open enrollment will become effective October 1, 2025.

WHAT’S NEW FOR 2025‐2026

Medical insurance is renewing with FL Blue

• Network will remain Blue Options

• Premium is increasing

Dental insurance is renewing with Florida Combined Life

• Premium is increasing

Vision Insurance is renewing with Standard

No change in premium

Life Insurance is renewing with Minnesota Life

• No change in voluntary life rates

Short- and Long-Term Disability Insurance are renewing with MetLife

• No change in rates

• As of 01/01/25 LTD is a city paid benefit

Health and Wellness Center

• Premise Health’s wellness incentive platform has changed from Inspire to Sonic Boom.

WELCOME

The City of Ocala is committed to providing our employees with a comprehensive benefits program to help you stay healthy and feel secure. This booklet will describe those benefits which include Medical, Dental, Vision, Life/AD&D, Voluntary Life, Disability and other Voluntary coverage. For a detailed description of these benefits please refer to the applicable Certificates of Coverage.

WHO WE COVER

Employees are eligible to participate in the City of Ocala employee benefits program:

if they work 30 or more hours a week. Coverage will be effective 1st of the month following 30 days of employment.

Dependent Eligibility

A dependent is defined as the participant’s legal spouse, or child(ren) (natural, newborn, adopted, foster or step) or for whom the participant has been court-appointed as legal guardian/custodian. Dependent children may be covered as follows:

Medical

To end of the calendar year following their 30th birthday Dental

To end of the calendar year following their 30th birthday Vision through the end of the year they turn 26 for whom the insured or insured’s spouse is legally responsible

Voluntary Life and Worksite To age 26

QUALIFIED LIFE EVENTS

Premiums for medical, dental, and vision insurance are deducted through a Cafeteria Plan established under Section 125 of the Internal Revenue Code (IRC) and are pre‐tax to the extent permitted. Under Section 125, changes to your pre‐tax benefits can be made ONLY during the Open Enrollment period unless you or your qualified dependents experience a qualifying event and the request to make a change is made within 30 days of the qualifying event. An “eligible” qualifying event is determined by the Internal Revenue Service (IRS) Code, Section 125.

• Divorce or legal separation (subject to State regulations)

• Marriage

• Birth, gain legal custody or adoption of child• Death of spouse, child or other qualified dependent

• Change in employment status for employee, spouse or dependent

• Gain or loss of other group coverage (including Medicare coverage)

• Change of dependent status• Change in residence due to an employment transfer

• Losing eligibility for coverage under a State Medicaid or CHIP (including Florida Kid Care) program (60-day notification period).

• An increase or decrease in your work hours causes eligibility or ineligibility

IMPORTANT

If you experience a qualifying event, you must contact Human Resources within 30 days of the qualifying event to make the appropriate changes to your coverage. Beyond 30 days, requests will be denied, and the employee may be responsible both legally and financially for any claim and/or expense incurred as a result of the employee or a dependent who continues to be enrolled but no longer meets eligibility requirements. You will be required to furnish valid documentation supporting a change in status or “Qualifying Event.”

BENTEK ONLINE BENEFITS ENROLLMENT SYSTEM

HOW TO ENROLL

MEDICAL INSURANCE TERMS

Coinsurance Coinsurance is the percentage of the medical services you are responsible to pay after the deductible has been met. Once you have met your deductible for the plan year, you pay the coinsurance amount up to the out-of-pocket maximum.

Copay A fee you pay every time you get medical care or a prescription. Copays can vary based on where you get care.

Deductible A deductible is the amount of money you must pay before the plan begins paying benefits for specified services. Deductibles do not apply to all services- see summary plan description for application.

Embedded Deductible Plan begins paying benefits that require cost sharing for the first family member who meets the per-person deductible. Once one or more of the remaining family members meet the family deductible the plan pays benefits for all covered family members.

Explanation of Healthcare Benefits (EOB) A letter you receive after getting care that shows costs, the amount the health plan is expected to pay and the amount you are expected to pay. You do not pay anything when you receive an EOB.

Non-Embedded Deductible When the family deductible is met the plan beings sharing costs for each member. The deductible can be met by one or combination of family members.

Out-of-Pocket Maximum The out-of-pocket maximum is the maximum amount you will pay, inclusive of copayments/coinsurance and deductibles for covered services, in a plan year. Once you have reached the out-of-pocket maximum during a policy year the plan pays any remaining eligible services at 100%.

Premium Your regular payment to your health plan. Generally, a higher premium means lower monthly out-of-pocket costs, and a lower premium means higher out-of-pocket costs. Your premium does not count towards your deductible or out-of-pocket maximum.

Plan Milestones and Stages

1. When your plan begins, you’re in the first stage. You pay for all your covered medical costs until you hit the deductible.

2. After hitting your deductible, you enter the next stage. You now pay only a percentage of your medical costs and the health plan pays the rest. This is the coinsurance stage of your plan.

3. The coinsurance stage lasts until you reach the out-of-pocket maximum. At that point, the plan starts paying for all covered medical costs for the rest of the plan year.

In-Network In-network refers to providers or health care facilities that are part of a health plan’s network of providers with which it has negotiated a discount. Insured individuals usually pay less when using an in-network provider because those networks provide services at lower cost to the insurance companies with which they have contracts. Example: You go to a doctor and the total charge is $250. You will receive a discount of $75 because you went to an in-network doctor and the negotiated rate with the doctor is lower. The insurance company pays $155. You pay what’s left, which is $20.

Out-of-Network Out-of-network refers to physicians, hospitals or other health care providers who are considered nonparticipants in an insurance plan or network. Depending on an individual’s health insurance plan, expenses incurred by services provided by out-of-network health professionals may not be covered or covered only in part by the individual’s insurance company. Example: You go to a doctor and the total charge is $250. You will not receive a discount because the doctor is out-of-network. The insurance company still pays $155, but you’ll be responsible for what’s left, which is $95.

MEDICAL INSURANCE TERMS

HEALTH RISK ASSESSMENT WELLNESS INCENTIVE

For limitations & exclusions, please refer to certificate of coverage or benefit summary.

FLORIDA BLUE MEDICAL INSURANCE

Network: BlueOptions

Website: www.floridablue.com

PPO 03359

Medical Plan Highlights Non‐NetworkPPO Network $1,500/ $3,000 (Family)$1,500/ $3,000 (Family)Annual Deductible

50%30%Coinsurance

$5,000/ $10,000 (Family)$3,000/ $6,000 (Family)Annual Out of Pocket Maximum (Includes Deductible & Copays)

50% CoinsuranceCovered 100%Preventive Care

Not covered$30 copay/ $60 copay/ $10 copayVirtual Visit (PCP/Specialist/Teledoc)

Deductible + Coinsurance$30 copay/ $60 copayOffice Visit (PCP/Specialist)

Deductible + Coinsurance Facility Fee (ASC): $100 copay

Hospital/Physicians Fees: Deductible + Coinsurance

Outpatient Surgery

Deductible + CoinsuranceDeductible + CoinsuranceInpatient Hospitalization

$300 copay$300 copayEmergency Room (Facility Only)

Deductible + $35 copay$35 copayUrgent Care

Deductible + CoinsuranceIndependent Lab $0, Diagnostic Test Center $50 copayLab/X-Ray

Deductible + Coinsurance$200 CopayAdvanced Imaging (CT, PET,MRI)

$100 Rx Deductible + 50% Coinsurance

$10 copay $100 Rx Deductible + $30 copay $100 Rx Deductible + $45 copay

Prescription Drugs Generic Preferred Brand Non-Preferred Brand

$100 Rx Deductible + 50% Coinsurance

$20 copay $60 copay $90 copay

Mail Order Prescription Generic Preferred Brand Non-Preferred Brand

Monthly Cost for Coverage

One Wellness Participant

No Wellness Participants

With Wellness Incentive

N/A$86.24$60.56Single

$302.00$343.72$289.66Family

FLORIDA BLUE MEDICAL INSURANCE

Network: BlueOptions

Website: www.floridablue.com

PPO 05902

Medical Plan Highlights Non‐NetworkPPO Network $2,500/ $5,000 (Family)$2,500/ $5,000 (Family)Annual Deductible

50%20%Coinsurance

$10,000/ $10,000 (Family)$5,000/ $10,000 (Family)Annual Out of Pocket Maximum (Includes Deductible & Copays)

50% CoinsuranceCovered 100%Preventive Care

Not Covered$40 copay/ $100 copayVirtual Visit (PCP/Specialist)

Deductible + Coinsurance$40 copay/ $100 copayOffice Visit (PCP/Specialist)

Deductible + CoinsuranceFacility/ Physician Fees: Deductible + CoinsuranceOutpatient Surgery

Deductible + CoinsuranceDeductible + CoinsuranceInpatient Hospitalization

Deductible + 20% CoinsuranceDeductible + CoinsuranceEmergency Room (Facility Only)

Deductible + $45 copay$45 copayUrgent Care

Deductible + Coinsurance Independent Lab: $0, Diagnostic Test Center: Deductible + Coinsurance

Lab/X-Ray

Deductible + CoinsuranceDeductible + CoinsuranceAdvanced Imaging (CT, PET,MRI)

$200 Rx Deductible + 50% Coinsurance

$20 copay $200 Rx Deductible + $40 copay $200 Rx Deductible + $60 copay

Prescription Drugs Generic Preferred Brand Non-Preferred Brand

$200 Rx Deductible + 50% Coinsurancee

$40 copay $200 Rx Deductible + $80 copay $200 Rx Deductible + $120 copay

Mail Order Prescription Generic Preferred Brand Non-Preferred Brand

Monthly Cost for Coverage

One Wellness Participant

No Wellness Participants

With Wellness Incentive

N/A$34.74$11.58Single

$202.74$233.70$192.02Family

ELECT RX MAIL ORDER PHARMACY

Chronic Conditions such as:

• Hypertension/High

Blood Pressure

• Diabetes/High Blood Sugar

• High cholesterol

• Heart disease

• Arthritis

• Depression

Acute Conditions such as:

• Headache and/or fever

• Urinary tract infection

• Minor injuries

• Back, neck, shoulder, knee and/or hip pain

Benefits of visiting your PCP:

• Low copay

• Medical history is available

• Established relationship with your doctor and clinical staff

• Cough, cold or flu

• Minor strains & sprains

• Bronchitis & sinus infection

• Skin & eye issues

• Upset stomach

• Urinary tract/bladder infections

• Rashes

• Pink eye

• Pediatric issues

• Psychological issues

• Visit with a licensed therapist

Benefits of virtual visits:

• 24/7 access to care

• Low copay

• Board certified physicians

• Nationwide network

• Available on smartphone or tablet

• Use when PCP, Urgent care or Extended Hour Care Center are unavailable to you

• Any life‐threatening emergency

• Any severe illness or injury

• Unresponsiveness

• Chest pain

• Weakness on one side

• Inability to speak

• Spine or head injury

• Change in mental status

• Difficulty breathing

• Uncontrolled bleeding

• Poisoning

• Severe abdominal pain

WHERE TO GO WHEN SEEKING MEDICAL ATTENTION

Do not pay more than you must for medical care. The emergency room is meant for emergencies such as life threating illnesses and injuries. Walk‐in‐clinics are designed to treat common ailments, provide basic primary health care, and are typically staffed by nurse practitioners and sometimes a physician’s assistant. Urgent care facilities are designed to treat patients who are suffering from acute, non-life-threatening illnesses and injuries that are beyond the capacities of a regular walk‐in‐clinic and are typically open for extended hours. To maximize savings, use in‐network facilities.

• Acute minor trauma

• Cough, cold or flu

• Upper respiratory infections

• Strains, sprains & fractures

• Minor allergic reactions and asthma attacks

• Immunizations

• Back, neck, shoulder, knee and/or hip pain

• Minor lacerations, burns and other small wounds

• Urinary tract/ bladder infections

Benefits of urgent care visits:

• Low copay

• Shorter wait time

• Same‐day appointments

• Significant savings over

ER

Reasons to see your Primary Care Physician:

Reasons to use a Virtual Visit:

Reasons to visit an Urgent Care:

Reasons to visit the Emergency Room:

EMPLOYEE HEALTH & WELLNESS CENTER

Overview

The Premise Health Employee Health and Wellness Clinic is available at no cost to all City health insurance plan members, age 8 and older. Overall, the City’s self-insured health insurance experiences significant savings when compared to what those services would have cost in the private market.

Services offered include:

- Primary Care

- Chronic Disease Management

- Lab, X-Ray and Bloodwork

- Generic Rx Medications

- Health and Wellness Coaching

New Account Registration

When registering a new account on mypremisehealth.com, employees are given a default login. The username is first initial + last name (no spaces) and the password is the last 6 digits of employee social security number. The access code for adding dependents is OCALA3.

Annual Health Assessment (AHA)

Employees and dependent spouses enrolled in a “With Wellness” health insurance plan must complete the AHA and follow-up appointment by September 30th of each year. The AHA provides a current evaluation of your overall health through a 28-panel blood draw, vitals, and health behavior questionnaire.

No Show Policy and Fee

The Premise Health Clinic operates like a normal medical office and relies on members keeping their appointments and arriving on time. An employee or retiree will be assessed a $25 surcharge if he/she, or their eligible dependent, has more than two instances of: not showing up for a scheduled appointment, not canceling an appointment at least one hour prior to the scheduled appointment time, and/or is more than ten minutes late to an appointment.

Hours

Monday - Thursday 7:00 am – 5:30 pm Friday 8:00 am – 5:00 pm

EMPLOYEE HEALTH & WELLNESS CENTER

SONIC BOOM WELLNESS INCENTIVE PLATFORM

Prescription Drug Cost Comparison Tools:

Use GoodRx and SingleCare’s drug price search to compare prices (just like you do for travel or electronics on other sites) for your prescription at pharmacies near you. GoodRx as well as SingleCare do not sell the medications, the free website and mobile app will tell you where you can get the best deal on them. If you have insurance, your co-pay might not be the best price. Hundreds of generic medications are available for $4 or even free without insurance. Every week both GoodRx and SingleCare collect millions of prices and discounts from pharmacies, drug manufacturers and other sources. GoodRx and SingleCare will show you prices, coupons, discounts and savings tips for your prescriptions at pharmacies near you. There is no cost or membership required to use either of these cost savings tools. Please visit the websites at www.goodrx.com and www.singlecare.com. You can also download these apps on your smartphone. Please note: amounts paid for prescriptions using GoodRx or SingleCare’s discount programs do not apply toward your medical plan’s deductible or annual out of pocket maximum.

Pharmacy Discount Programs:

Before you pay for your next prescription, check to see if they are available for free or at a lower cost than traditional copays. Pharmacies such as Wal-Mart, Costco, CVS/Target, and Publix offer prescription discount programs that allow you to purchase medications for as low as $4 for a 30 day Supply (see each Pharmacy for specifics on their prescription discount program). If your local pharmacy is not listed below, please check with them to see if they offer any discounts.

COST SAVINGS TOOLS

EAGLES, BENEFITS BY DESIGN FLEXIBLE SPENDING ACCOUNT (FSA)

You can pay for out‐of‐pocket medical, dental, vision, and/or dependent care expenses with pre‐tax dollars through the Flexible Spending Account (FSA). Important Note: If you will be funding an HSA, you cannot participate in the Health Care FSA.

Health Care FSA features:

• Plan year begins October 1st annually and ends September 30th

• Pre-tax contribution

• Pay for any qualified medical, dental, and vision expenses for yourself, spouse, or dependents. (See IRS Publication 502 for a complete list of qualified medical expenses- sample list is below.

A Dependent Care FSA is used to reimburse work related expenses; while you or your spouse work, look for work or attend school full‐time or are physically unable to care for your dependent. Eligible children are under age 13, or a dependent who is physically or mentally not able to care for himself. Eligible expenses include nanny, nursery school, before care/after care, late pick‐up fees, day camp, or day care. Your Dependent Care contribution is not pre‐loaded to a debit card; you can only access what has been payroll deducted and is in your FSA.

You should contribute the amount of money you expect to pay out‐of‐pocket for eligible expenses incurred during the Plan Year. All eligible expenses must be incurred on or before September 30 in order to be eligible for reimbursement for that plan year. If you still have money in the account at the end of the plan year (September 30, 2025), you will have a 90-day run out period to submit for expenses that occurred during the previous plan year. The FSA debit card cannot be used for the runout period for prior year expenses.

When a transaction is marked as ineligible, it means that the FSA debit card was used to pay for something that is not FSA eligible per the IRS, or that receipts were never provided to show eligibility. It is the participants responsibility to provide documentation or reconcile the charges before the end of the runout period.

Health care FSA participants can rollover up to $660 from one plan year to the next. Dependent care FSA participants do not have a rollover option.

2025Maximum Annual Contributions

$3,300Health Care Contribution Limit

$5,000Dependent Care Contribution Limit

$2,500- If married filing separately

For dental frequencies, please refer to certificate of coverage or benefit summary.

FLORIDA BLUE DENTAL INSURANCE

Network: Choice Plus Website: www.floridabluedental.com

Low PPO Plan Benefits

Non-NetworkPPO Network $50/ $150 (Family)$50/ $150 (Family)Annual Deductible

$1,000$1,000Annual Plan Maximum

$1,000$1,000Orthodontia Lifetime Maximum

Diagnostics & Preventive Services

90%100%Exams, Cleanings, X-Rays

Basic Services

60%80%Fillings, Extractions, Root Canals

Major Services

40%50%Crowns, Bridges, Dentures

Orthodontic Services

50%50%Orthodontia Treatment

• Deductible does not apply to preventive services

• If you use a non‐network provider, you are responsible for paying the difference in cost between the non‐network provider’s charges and the allowed amount.

Monthly Cost for Coverage

$31.84Employee Only

$49.35Employee + One

$77.91Employee + Two or more

For dental frequencies, please refer to certificate of coverage or benefit summary.

FLORIDA BLUE DENTAL INSURANCE

Network: Choice Plus Website: www.floridabluedental.com

High PPO Plan Benefits

Non-NetworkPPO Network $50/ $150 (Family)$50/ $150 (Family)Annual Deductible

$1,000$1,000Annual Plan Maximum

$1,000$1,000Orthodontia Lifetime Maximum

Diagnostics & Preventive Services

100%100%Exams, Cleanings, X-Rays

Basic Services

80%80%Fillings, Extractions, Root Canals

Major Services

50%50%Crowns, Bridges, Dentures

Orthodontic Services

50%50%Orthodontia Treatment

• Deductible does not apply to preventive services

• If you use a non‐network provider, you are responsible for paying the difference in cost between the non‐network provider’s charges and the allowed amount.

Monthly Cost for Coverage

$43.55Employee Only

$67.62Employee + One

$106.64Employee + Two or more

STANDARD VISION INSURANCE

Network: EyeMed Select Website: www.eyemedvisioncare.com

Vision Benefits

Non-Network Reimbursements

PPO Network

No deductible$4 Exam/ $10 LensesDeductibles

Up to $30Covered in FullEye Exams

Eyeglass Lenses and Frames

Up to $20Covered in FullSingle Standard Lenses

Up to $40Covered in FullBifocal Standard Lenses

Up to $60Covered in FullTrifocal Standard Lenses

Not covered20% discountLenticular Standard Lenses

Up to $45Up to $100, 20% discount on remaining balance

Frames

Contact Lenses

Not coveredUp to $40Standard Fit and Follow Up

Up to $85Up to $100, 15% discount on remaining balance

Elective Lenses

Up to $200Covered in fullMedically Necessary Lenses

Frequency

12 monthsEye Exam

12 monthsLenses—Eyeglass or Contact

12 monthsFrames

For limitations & exclusions, please refer to certificate of coverage or benefit summary.

Monthly Cost for Coverage

$5.20Employee Only

$10.36Employee + One

$16.24Employee + Two or more

MINNESOTA LIFE

BASIC LIFE/AD&D & VOLUNTARY LIFE INSURANCE

Life insurance protects your family or other beneficiaries in the event of your death. The death benefit helps replace the income you would have provided and can help meet important financial needs. It can help pay your mortgage, rent, run your household, send your children to college, pay off debts, etc. The City of Ocala provides eligible, full-time employees a Life and AD&D benefit at no cost to the employee. Employees can also enroll in voluntary Life and AD&D insurance at a group rate for themselves, spouses, and children up to the age of 26.

Important Reminders

• Group AD&D Insurance terminates when an employee reaches age 70.

• You must be actively at work on the effective date, or your coverage will be delayed until you return to active employment.

• Evidence of Insurability (EOI) is required for employees who want to increase coverage at Open Enrollment and for new hires electing over the Guarantee Issue.

For Limitations & Exclusions, please refer to the certificate of coverage or benefit summary.

Summary: Voluntary Life insurance

Employee Coverage (rate based on employee age) Guarantee Issue $150,000 Maximum Benefit Amount $500,000 Increments of $10,000 *Not to exceed 5x annual salary

Spouse Coverage (rate based on employee age) Spouse Guarantee Issue $30,000 Maximum Benefit Amount $250,000 Increments of $5,000

* Not to exceed 100% of employee’s total basic + supplemental coverage amounts.

Child(ren) Coverage Birth to 26 years $10,000

Dependent Life $10,000 spouse and Package $10,000 children

How to calculate your Voluntary Life/AD&D costs per paycheck:

1. Indicate your elected benefit amount (EBA)

2. Divide EBA by $1,000

3. Enter age rate from cost table

4. Multiply Step 2 by Step 3

5. Multiply Step 4 by 12 then divide by number of pay-cycles (24 or 26) to calculate your cost per paycheck

Rate per 1,000Employee Age

$0.063Under 25

$0.07525 – 29

$0.10030 – 34

$0.11335 – 39

$0.15040 – 44

$0.26345 – 49

$0.46350 – 54

$0.76355 – 59

$0.93860 – 64

$1.63865 – 69

$2.57570 – 74

$2.97575

Available upon request75+

$1.30Child Life

$4.95 per unitDependent Pkg

*One premium insures all eligible children

METLIFE VOLUNTARY SHORT‐TERM DISABILITY

For Limitations & Exclusions, please refer to the certificate of coverage or benefit summary.

If you become unable to perform your regular job duties for an extended time due to sickness or accidental injury, you can be covered by the short-term disability (STD) policy.

Your income replacement benefit would equal 60% of your basic weekly earnings. The maximum weekly benefit you can receive is $1,000. Benefits begin to accrue on the day after you have been unable to work for 14 days due to a covered sickness or accident and will continue to be paid for 13 weeks. Your STD benefit will be reduced by any disability income you receive from other sources, such as Social Security, worker’s compensation, and/or state disability plans.

The STD plan contains a pre-existing condition exclusion. The exclusion applies only to conditions for which medical advice, diagnosis, care or treatment was recommended or received or for which a reasonably prudent person would have sought care within the 6-month period prior to the effective date of coverage and the disability begins within 12 months of the effective date of coverage.

The Estimated Rate Calculation below will be based on your annual salary and your age. The final premium calculations will be done by MetLife.

Short-Term Disability Calculation – Cost Per Paycheck A. Enter your annual salary B. Divide your annual salary by 52

60%C. Enter the weekly benefit percentage D. Multiply “B” times “C”

$1,000E. Enter the maximum weekly benefit F. Enter the lesser of “D” or “E”. This is your benefit amount G. Multiply “F” times your monthly rate per $10 of benefit H. Divide “G” by $10 I. Multiply “H” by 12 J. Enter the annual pay cycle K. Divide “I” by “J”. This is your premium (cost per paycheck)

Short-Term Disability Calculation – Example 43-year-old, 13 weeks, $60,000 annual salary

$60,000A. Enter your annual salary $1,153.85B. Divide your annual salary by 52

60%C. Enter the weekly benefit percentage $692.31D. Multiply “B” times “C” $1,000E. Enter the maximum weekly benefit $692.31F. Enter the lesser of “D” or “E”. This is your benefit amount $283.85G. Multiply “F” times your monthly rate per $10 of benefit $28.38H. Divide “G” by $10 $340.62I. Multiply “H” by 12

24J. Enter the annual pay cycle $14.19K. Divide “I” by “J”. This is your premium (cost per paycheck)

13 weeks Rate per

$10 Employee Age

$0.39Under 25

$0.4125 but < 30

$0.4230 but < 35

$0.3835 but < 40

$0.4140 but < 45

$0.4945 but < 50

$0.6150 but < 55

$0.7555 but < 60

$0.8960 but < 65

$1.0765 or older

METLIFE VOLUNTARY LONG‐TERM DISABILITY

For Limitations & Exclusions, please refer to the certificate of coverage or benefit summary.

If you become unable to perform your regular job duties for an extended time due to sickness or accidental injury, you can be covered by the long-term disability (LTD) policy. This benefit is provided by the city at no cost to all eligible full-time employees.

Your income replacement benefit would equal 60% of your basic monthly earnings. The maximum monthly benefit you can receive is $10,000. Benefits begin after you have been unable to work for 90 days due to a covered sickness or accident and will continue to be paid to the later of your normal retirement age or as determined by the LTD age chart provided by MetLife.

Your LTD benefit will be reduced by any disability income you receive for other sources, such as Social Security, worker’s compensation, and/or state disability plans.

The LTD plan contains a pre-existing condition exclusion. The exclusion applies only to conditions for which medical advice, diagnosis, care or treatment was recommended or received or for which a reasonably prudent person would have sought care within the 6-month period prior to the effective date of coverage and the disability begins within 12 months of the effective date of coverage.

AETNA EMPLOYEE ASSISTANCE PROGRAM (EAP)

LEGAL SHIELD LEGAL INSURANCE

ALLSTATE ACCIDENT INSURANCE

Accident Insurance arranged through Allstate offers protection for accidental injuries on-and-off the job, 24 hours a day. This coverage help pick up where other insurance leaves off and provides a cash benefit, directly to you, to cover the associated expenses due to an accidental injury. Coverage is guaranteed, meaning no medical questionnaire to complete, and is available to you and your dependents. Both a base (plan 1) and buy-up (plan2) plan are available.

ALLSTATE CANCER INSURANCE

Cancer Insurance offered through Allstate and pays a cash benefit to help with the costs associated with treatments, daily living expenses, and to empower you to seek the care you need. The coverage is guaranteed issue, meaning that no medical questionnaire is required for initial enrollment and the benefits are paid directly to you. The plan includes coverage for cancer as well as 29 specified diseases. Coverage is available for dependents and can be continued if you leave employment. For employees only, a waiver of premium is available after 90 days of disability due to cancer as long as your disability lasts. Both a base (plan 1) and buy-up (plan2) plan are available.

PLAN 1 PREMIUMS

FamilyEE+CHEE+SPEE onlyMode

$18.48$12.30$13.44$7.26Semi-Monthly

PLAN 2 PREMIUMS

FamilyEE+CHEE+SPEE onlyMode

$27.18$17.91$19.62$10.35Semi-Monthly

PLAN 1 PREMIUMS

FamilyEE onlyMode

$14.76$8.62Semi-Monthly

PLAN 2 PREMIUMS

FamilyEE onlyMode

$23.74$14.06Semi-Monthly

For more information please visit: https://www.allstatevoluntary.com/ocala/

ALLSTATE CRITICAL ILLNESS

Critical Illness Insurance arranged through Allstate helps prepare you for a life-altering critical illness diagnosis. The treatment required for recovery is vital be can be very expensive. Medical coverage may only cover some of the associated costs leaving you with the cost for the deductible and coinsurance.

Critical Illness coverage provides financial support by paying a cash benefit based on the percentage payable for a covered critical illness. Coverage is guarantee issue, meaning no medical questionnaire needs to be completed at initial enrollment. Coverage is available for dependents who are eligible for 50% of your basic benefit amount. Benefits are paid regardless of any other medical or disability coverage and can be taken with you if you leave employment. Both a base (plan 1) and buy-up (plan2) plan are available.

PLAN 1 SEMI‐MONTHLY PREMIUM ‐ Non‐Tobacco

FamilyEE+CHEE+SPEE onlyAge

$2.60$1.66$2.50$1.6118-35

$4.70$3.06$4.65$3.0136-49

$8.70$5.76$8.60$5.7150-59

$13.30$8.86$13.25$8.8160-64

$16.90$11.26$16.80$11.2165-69

$20.10$13.51$20.00$13.4670+

PLAN 1 SEMI‐MONTHLY PREMIUM ‐ Tobacco

FamilyEE+CHEE+SPEE onlyAge

$3.50$2.21$3.40$2.1618-35

$7.45$4.91$7.45$4.9136-49

$15.50$10.41$15.45$10.3150-59

$21.75$14.61$21.75$14.5660-64

$25.20$16.96$25.15$16.8665-69

$28.40$19.06$28.30$19.0170+

PLAN 2 SEMI‐MONTHLY PREMIUM ‐ Non‐Tobacco

FamilyEE+CHEE+SPEE onlyAge

$4.10$2.64$3.90$2.5418-35

$8.30$5.44$8.20$5.3436-49

$16.30$10.84$16.10$10.7450-59

$25.50$17.04$25.40$16.9460-64

$32.70$21.84$32.50$21.7465-69

$39.10$26.34$38.90$26.2470+

PLAN 2 SEMI‐MONTHLY PREMIUM – Tobacco

FamilyEE+CHEE+SPEE onlyAge

$5.90$3.74$5.70$3.6418-35

$13.80$9.14$13.80$9.1436-49

$29.90$20.14$29.80$19.9450-59

$42.40$28.54$42.40$28.4460-64

$49.30$33.24$49.20$33.0465-69

$55.70$37.44$55.50$37.3470+

For more information please visit: https://www.allstatevoluntary.com/ocala/

NATIONWIDE PET INSURANCE

Newborns’ and Mothers’ Health Protection Act

Group health plans and health insurance issuers 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 vaginal delivery, or less than 96 hours following a cesarean-section.

However, federal law generally does not prohibit the mother's or newborn's attending provider, after consulting with the mother, from discharging the mother of her newborn earlier than 48 hours (or 96 hours as applicable).

In any case, plans and issuers may not, under federal law, require that a provider obtain authorization from the plan or issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours if applicable).

Genetic Information Nondiscrimination Act

(GINA)

The Genetic Information Nondiscrimination Act of 2008 protects employees against discrimination based on their genetic information. Unless otherwise permitted, your employer may not request or require any genetic information from you or your family members.

GINA prohibits employers and other entities covered by GINA Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law.

To comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. “Genetic Information” as defined by GINA, includes an individual’s family medical history, the results of genetic tests, the fact that an individual sought or received genetic services, and genetic information about a fetus carried by an individual or family member, or of an embryo legally held by an individual or family member using assisted reproductive technology.

Mental Health Parity and Addiction Equity Act (MHPAEA)

The Mental Health Parity and Addiction Act of 2008 general requires group health plans and health insurance issuers to ensure that financial requirements (such as co‐pays and deductibles) and treatment limitations (such as annual visit limits) applicable to mental health or substance use disorder benefits are no more restrictive than the predominant requirements or limitations applied to substantially all medical/surgical benefits. For more Information regarding the criteria for medical necessity determinations made under your employer's plan with respect to mental health or substance use disorder benefits, please contact HR at (352)629-8359.

Michelle’sLaw

When a dependent child loses student status for purposes of the group health plan coverage as a result of a medically necessary leave of absence from a post‐ secondary educational institution, the group health plan will continue to provide coverage during the leave of absence for up to one year, or until coverage would otherwise terminate under the group health plan, whichever is earlier.

For additional information, contact HR at (352)629- 8359.

Women’s Health and Cancer RightsAct

If you have had or are going to have a mastectomy, you may be entitled to certain benefits under the Women's Health and Cancer Rights Act of 1998 (WHCRA). The Women's Health and Cancer Rights Act requires group health plans and their insurance companies and HMOs to provide certain benefits for mastectomy patients who elect breast reconstruction. For individuals receiving mastectomy‐related benefits, coverage will be provided in a manner determined in consultation with the attending physician and the patient, for:

All stages of reconstruction of the breast on which the mastectomy was performed;

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

Prostheses; and

Treatment of physical complications of the mastectomy, including lymphedema.

Breast reconstruction benefits are subject to deductibles and co‐insurance limitations that are consistent with those established for other benefits under the plan. If you would like more information on WHCRA benefits, contact HR at (352)629-8359.

IMPORTANT NOTICES

Notice of Special Enrollment Rights

This notice is being provided to help you understand your right to apply for group health coverage. You should read this notice even if you plan to waive health coverage at this time.

Loss of Other Coverage If you are declining coverage for yourself or your dependents (including your spouse) because of other health insurance or group health plan coverage, you may be able to enroll yourself and your dependents in this Plan if you or your dependents lose eligibility for that other coverage (or if the employer stops contributing toward your or your dependents’ other coverage). However, you must request enrollment within 30 days after your or your dependents’ other coverage ends (or after the employer stops contributing toward the other coverage).

Marriage, Birth or Adoption If you have a new dependent as a result of a marriage, birth, adoption, or placement for adoption, you may be able to enroll yourself and your dependents. However, you must request enrollment within 30 days after the marriage, birth, or placement for adoption.

Medicaid or CHIP If you or your dependents lose eligibility for coverage under Medicaid or the Children’s Health Insurance Program (CHIP) or become eligible for a premium assistance subsidy under Medicaid or CHIP, you may be able to enroll yourself and your dependents. You must request enrollment within 60 days of the loss of Medicaid or CHIP coverage or the determination of eligibility for a premium assistance subsidy.

To request special enrollment or obtain more information, please contact HR at (352)629-8359.

Uniformed Services Employment and Re- Employment Rights Act of 1994 (USERRA)

The Uniformed and Services Employment and Re- Employment rights Act of 1994 (USERRA) sets requirements for continuation of health coverage and re-employment in regard to an Employee’s military leave of absence. These requirements apply to medical and dental coverage for you and your Dependents. They do not apply to any Life, Short Term or Long-Term Disability or Accidental Death & Dismemberment coverage you may have. A full explanation of USERRA and your rights is beyond the scope of this document. If you want to know more, please see the Summary Plan Description (SPD) for any of our group insurance coverage or go to this site:

http://www.dol.gov/vets/programs/userra

An alternative source is VETS. You can contact them at 1- 866-4-USA-DOL or visit this site: http://www.dol.gov/vets An interactive online USERRA Advisor can be viewed at http://www.dol.gov/elaws/userra.htm

IMPORTANT NOTICES

Notice Regarding Wellness Programs

The City of Ocala Wellness Program is a voluntary wellness program available to employees. The program is administered according to federal rules permitting employer-sponsored wellness programs that seek to improve employee health or prevent disease, including the Americans with Disabilities Act of 1990, the Genetic Information Nondiscrimination Act of 2008, and the

Health Insurance Portability and Accountability Act, as applicable, among others. If you choose to enroll yourself or your spouse in a “with wellness” health insurance plan, you will be asked to complete a Health Risk Assessment or "HRA" that asks a series of questions about your health-related activities and behaviors and whether you have or had certain medical conditions (e.g., cancer, diabetes, or heart disease). You and your spouse if applicable, will also be asked to complete a biometric screening, which will include a health questionnaire, 28-panel blood draw, and vital sign screening to measure your cholesterol levels, nutrition, liver function, chemistry levels and more. You are not required to complete the HRA or to participate in the blood test or other medical examinations.

However, employees and spouses who choose to participate in the wellness program will receive a reduction in medical premium as an incentive for completing the HRA. Although you are not required to complete the HRA or participate in the biometric screening, only employees who do so will receive a premium reduction.

The information from your HRA and the results from your biometric screening will be used to provide you with information to help you understand your current health and identify potential risk of diabetes, hypertension and other health concerns that could become more serious if not detected early. You also are encouraged to share your results or concerns with your own doctor.

Protections from Disclosure of Medical Information

We are required by law to maintain the privacy and security of your personally identifiable health information. Although the wellness program and may use aggregate information it collects to design a program based on identified health risks in the workplace, City of Ocala Wellness Program will never disclose any of your personal information either publicly or to the employer, except as necessary to respond to a request from you for a reasonable accommodation needed to participate in the wellness program, or as expressly permitted by law. Medical information that personally identifies you that is provided in connection with the wellness program will not be provided to your supervisors or managers and may never be used to make decisions regarding your employment.

Your health information will not be sold, exchanged, transferred, or otherwise disclosed except to the extent permitted by law to carry out specific activities related to the wellness program, and you will not be asked or required to waive the confidentiality of your health information as a condition of participating in the wellness program or receiving an incentive. Anyone who receives your information for purposes of providing you services as part of the wellness program will abide by the same confidentiality requirements. The only individual(s) who will receive your personally identifiable health information are you, your attending physician and Florida Blue in order to provide you with services under the wellness program.

In addition, all medical information obtained through the wellness program will be maintained separate from your personnel records, information stored electronically will be encrypted, and no information you provide as part of the wellness program will be used in making any employment decision. Appropriate precautions will be taken to avoid any data breach, and in the event a data breach occurs involving information you provide in connection with the wellness program, we will notify you immediately.

You may not be discriminated against in employment because of the medical information you provide as part of participating in the wellness program, nor may you be subjected to retaliation if you choose not to participate.

If you have questions or concerns regarding this notice, or about protections against discrimination and retaliation, please contact

HR at (352)629-8359.

Your Information.

Your Rights.

Our Responsibilities.

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.

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

• You can ask to see or get a copy of your health and claims records and other health information we have about you. Ask us how to do this.

• We will provide a copy or a summary of your health and claims records, usually within 30 days of your request. We may charge a reasonable, cost-based fee.

Get a copy of your health and claims records

• You can ask us to correct your health and claims records if you think they are incorrect or incomplete. Ask us how to do this.

• We may say “no” to your request, but we’ll tell you why in writing within 60 days.

Ask us to correcthealth and claims records

• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.

• We will consider all reasonable requests, and must say “yes” if you tell us you would be in danger if we do not.

Request confidential communications

• You can ask us not to use or share certain health information for treatment, payment, or our operations.

• We are not required to agree to your request, and we may say “no” if it would affect your care.

Ask usto limit what we use orshare

• You can ask for a list (accounting) of the times we’ve shared your health information for six years prior to the date you ask, who we shared itwith, and why.

• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We’ll provide one accounting a year for freebut will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a list ofthose with whom we’ve shared information

• You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Get a copy of this privacy notice

• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

• We will make sure the person has this authority and can act for you before we take any action.

Choose someone to act for you

• You can complain if you feel we have violated your rights by contacting us using the information on page 1.

• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints/.

• We will not retaliate against you for filing a complaint.

File a complaint if you feel your rights are violated

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

• Share information with your family, close friends, or others involved in payment for your care

• Share information in a disaster relief situation

• Contact you for fundraising efforts

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases, you have both the right andchoice to tell us to:

• Marketing purposes

• Sale of your information

In these cases, we never share your information unless you give us written permission:

How do we typically use or share your health information? We typically use or share your health information in the following ways.

Example: A doctor sends us information about your diagnosis and treatment plan so we can arrange additional services.

• We can use your health information and share it with professionals who are treating you.

Help manage the health care treatment you receive

Example: We use health information about you to develop better services for you.

• We can use and disclose your information to run our organization and contact you when necessary.

• We are not allowed to use genetic information to decide whether we will give you coverage and the price of that coverage. This does not apply to long term care plans.

Run our organization

Example: We share information about you with your dental plan to coordinate payment for your dental work.

• We can use and disclose your health information as we pay for your health services.

Pay for your health services

Example: Your company contracts with us to provide a health plan, and we provide your company with certain statistics to explain the premiums we charge.

• We may disclose your health information to your health plan sponsor for plan administration.

Administer your plan

Our Uses and Disclosures

How else can we use or share your health information? We are allowed or required to share your information in other ways – usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see:

www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html.

• We can share health information about you for certain situations such as:

• Preventing disease

• Helping with product recalls

• Reporting adverse reactions to medications

• Reporting suspected abuse, neglect, or domestic violence

• Preventing or reducing a serious threat to anyone’s health or safety

Help with publichealth and safety issues

• We can use or share your information for health research.Do research

• We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we’re complying with federal privacy law.

Comply with thelaw

• We can share health information about you with organ procurement organizations.

• We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Respond to organ and tissue donation requests and work with a medical examiner or funeral director

• We can use or share health information about you:

• For workers’ compensation claims

• For law enforcement purposes or with a…