CHEIBA Trust Employee Benefit Plan
2017 Plan Year
IMPORTANT
INFORMATION INCLUDED INSIDE ABOUT
1) MEDICARE PART D - NOTICE OF CREDITABLE COVERAGE AND
2) CONTINUATION RIGHTS UNDER COBRA
Sponsored by - Colorado Higher Education Insurance Benefits Alliance Trust (CHEIBA Trust)



CHEIBA TRUST MEMBERS
2017

Benefit Plan Year
ADAMS STATE UNIVERSITY


A

URARIA HIGHER EDUCATION CENTER



COLORADO SCHOOL OF MINES





COLORADO STATE UNIVERSITY – GLOBAL
CAMPUS

COLORADO STATE UNIVERSITY – PUEBLO

FORT LEWIS COLLEGE

METROPOLITAN STATE UNIVERSITY OF DENVER

UNIVERSITY OF NORTHERN COLORADO

WESTERN STATE COLORADO UNIVERSITY



If you have Medicare or will become eligible for Medicare in the next 12 months, a Federal
law gives you more choices about
your prescription drug coverage. Please see pages 51 and
52 for more details.






PLAN CONTACTS
2017 EMPLOYEE BENEFIT INSURANCE
Health Insurance
Anthem Blue Cross and Blue Shield
www.anthem.com
BlueAdvantage Point of Service Plan (HMO/POS)
PRIME Blue Priority Plan (PPO) and Custom Plus Health Plan
Blue Priority HMO Plan
Lumenos High Deductible Health Plan
Phone .......................................................................................................................................................... 1-800-542-9402
Provider Directories for Health and Dental www.anthem.com
HMO Landmark Healthcare (chiropractor, acupuncture, massage therapy, nutritional counseling) ...... www.landmarkhealthcare.com
Phone .......................................................................................................................................................... 1-800-638-4557
Future Moms ................................................................................................................................................. 1-800-828-5891
24/7 NurseLine .............................................................................................................................................. 1-800-337-4770
LiveHealth Online .......................................................................................................................................... 1-855-603-7985
Prescription Drug Benefit

Express Scripts Mail Order .......................................................................................................................... 1-866-297-1011
Accredo (Specialty Drugs) ........................................................................................................................... 1-800-870-6419
Dental Insurance
Anthem Blue Cross and Blue Shield
www.anthem.com
Anthem Blue Dental PPO Plus
Anthem Blue Dental PPO
Phone .......................................................................................................................................................... 1-800-627-0004
Vision Insurance
Anthem Blue Cross and Blue Shield
www.anthem.com
Phone .......................................................................................................................................................... 1-866-723-0515
Discount Information…………………………………………………………………………………………………….. www.anthem.com/specialoffers
Basic Term Life Insurance & Voluntary Term Life
Anthem Life Insurance Company
www.anthem.com
Phone .......................................................................................................................................................... 1-866-594-0516
Voluntary Accidental Death & Dismemberment Insurance
Mutual of Omaha Insurance Company
www.mutualofomaha.com
Phone .......................................................................................................................................................... 1-800-524-2324
Flexible Benefit Plan
24HourFlex (Except Fort Lewis College – See Separate Insert)
www.24hourflex.com
Phone .......................................................................................................................................................... 1-800-651-4855
Email .................................................................................................................................................. info@24hourflex.com
Participant Website ...................................................................................................... https://participant.24hourflex.com
Long Term Disability Insurance
Standard Insurance Company
www.standard.com
Phone .......................................................................................................................................................... 1-800-368-1135
Colorado State Employee Assistance Program (C-SEAP) .......................................... www.colorado.gov/c-seap
Phone ................................................................................................................ 303-866-4314 or Toll Free 1-800-821-8154
Travel Accident Insurance
Chubb
Phone .......................................................................................................................................................... 1-888-987-5920
E-Mail ops@europassistance-usa.com
Participant Advocate Link (P.A.L.)
Arthur J. Gallagher & Co.

Phone .............................................................................................................................. 303-889-2692 or 1-800-943-0650
Fax ................................................................................................................................................................... 303-889-2693
E-Mail PAL_GBI@ajg.com
COBRA Coverage
HealthSmart
Phone .......................................................................................................................................................... 1-800-423-4445
E-Mail askcobra@healthsmart.com



TABLE OF CONTENTS
Benefit Eligibility ................................................................................ 2

Benefit Changes ................................................................................ 5
Benefit Termination ........................................................................... 7
Benefit Highlights .............................................................................. 8

Medical Plan .................................................................................... 11
Medical Plan Comparison ............................................................... 12

Dental Plan ..................................................................................... 23

Vision Plan ...................................................................................... 25

Basic Term Life Insurance ............................................................... 30

Voluntary Life & AD&D .................................................................... 32

Flexible Benefit Plan ........................................................................ 34

Long Term Disability ........................................................................ 39

Employee Assistance Program ......................................................... 41

Travel Accident ................................................................................ 42

Legal Notices ................................................................................... 43

Glossary of Terms ............................................................................ 53




INTRODUCTION




CHEIBA Trust

Employee Benefit Plan

The Colorado Higher Education Insurance Benefits Alliance
Trust (CHEIBA Trust) and the CHEIBA Trust Members are
pleased to announce your Employee benefit choices
effective for 2017. The information in this booklet provides a
comprehensive overview of your benefits package to help
you in making the choices that best meet your individual and
family needs.

Please read the benefit summaries carefully before completing your Election Forms. There have been additions
and changes to your benefits for the 2017 plan year. If you have questions or concerns, phone numbers and
website addresses are included for your convenience.

As an additional resource to this booklet, please also visit the CHEIBA Trust
member webpage (www.mybensite.com/cheiba) to find more detailed plan
summaries, forms, contacts and much more. We encourage you to become
familiar with and use the resources offered through the web portal.
Login: cheiba
Password: benefits


Authority of the CHEIBA Trust Committee
The CHEIBA Trust Committee has the sole and absolute discretion to interpret the terms of a Plan and determine the right of any
Participant to receive benefits under a CHEIBA Trust Plan. The right of any Participant to receive benefits under a fully insured
benefit plan shall be determined by the insurance company pursuant to the terms of its insurance contract and certificate of
insurance. The CHEIBA Trust Committee’s decision is final, conclusive and binding upon all parties.

Disclaimer: These benefits are designed to meet your individual needs and preferences. While we expect to offer these benefits in future years, the
CHEIBA Trust retains the right to discontinue or change the benefits at any time. Changes will be communicated, in writing, to all benefit-eligible
Employees.

In preparing these written materials, every attempt has been made to convey accurate information. The materials provide a summary of your benefits to
be used as reference throughout the plan year. In the event of a discrepancy between the information contained herein and the Trust Agreement, a plan
document or certificate of insurance under which a specific benefit or insurance is provided, the terms of the plan document or certificate of insurance
shall take precedence over this booklet and shall prevail in settling any disputes or claims that may arise. If errors or discrepancies are found, contact
your Human Resources/Benefits Office for the official plan document.

-1-

BENEFIT ELIGIBILITY


BENEFIT ELIGIBILITY
Benefits under the CHEIBA Trust Plans are available to Eligible Employees and Dependents of the State colleges, universities and institutions of higher
education who participate in the CHEIBA Trust.

Employee
“Employee” definition will be defined by each of the State colleges, universities and institutions who
participate in the CHEIBA Trust. Please see the Eligibility document for your campus/institution. Eligible
Employees on an authorized leave of absence not to exceed a 24-consecutive month period, including
Employees on sabbatical and summer break, may be included as Eligible Employees until the Employer
notifies the insurance company of termination of eligibility.
Dependent
A. "Dependent" means an Employee's (a) legal spouse; (b) partner in a civil union pursuant to CRS §14-15-
101, et seq.; and (c) an Employee’s married or unmarried child or children until the end of the month of
their 26th birthday. Dependents must also satisfy the requirements of the Internal Revenue Code to
qualify as tax dependents of the Employee for life insurance purposes and satisfy the eligibility
requirements for coverage under a Benefit Plan. A Dependent shall also include any dependent which is
required by State insurance law to be covered or offered coverage under any insurance contract issued
to the Trust for a Benefit Plan.
B. For the purposes of paragraphs A above, the term “child” or “children” shall include a natural or
biological child, child of a partner in a civil union, step-child, legally adopted child, child under legal
guardianship, child or children of any age who are medically certified by a physician as disabled, and a
child for whom the Employee is required to provide health benefits pursuant to a court order or
qualified medical child support order, provided however, the term “child” or “children” shall not include
the grandchild or grandchildren of the Employee.
C. For the purposes of an Anthem certificate of insurance evidencing medical, dental and voluntary life
coverage, any reference to the term "spouse" shall also include a partner in a civil union.
Civil Union Benefits
Pursuant to the Colorado Civil Union Act, CRS §14-15-101, et seq., the CHEIBA Trust modified the definition
of “Dependent” to include partners in a civil union of covered Employees effective as of January 1, 2014. A
Civil Union is a relationship established by two eligible persons pursuant to CRS §14-15-103(1) that entitles
them to receive the benefits and protections and be subject to the responsibilities of spouses. This means
that Civil Union Partners are eligible for group medical, dental, voluntary vision, voluntary life and voluntary
accidental death and dismemberment benefits offered by the CHEIBA Trust Members.

Eligibility for Coverage
Civil Union Partners and their eligible dependents will be eligible for medical, dental, term life, voluntary
vision, voluntary life and voluntary accidental death and dismemberment insurance in the same manner
as for an Employee's spouse and other dependent children.

Enrollment Procedure
Enrolling a Civil Union Partner is subject to the same limitations that apply to a spouse or child.
Enrollment is limited to:
- within 31 days of being hired into a benefits eligible appointed position, or
- during an annual Open Enrollment period for benefits effective the following January 1st, or
- within 31 days of all qualified IRS-defined change of status (e.g., birth/adoption of a child or loss of a
partner's coverage through his or her employer), or
- within 31 days of the issuance of a valid civil union certificate.

To enroll, the Employee must present the civil union certificate to your Human Resources/Benefits Office.
-2-

BENEFIT ELIGIBILITY


Dissolution, Legal Separation and Invalidity of Civil Unions
In accordance with CRS §14-15-115(2), the dissolution, legal separation and invalidity of civil unions shall
follow the same procedures as the dissolution, legal separation and invalidity of marriages.
Flex Plans
If the Civil Union Partner and his/her children are the Employee's tax dependents for medical and dental
plan purposes, and the Employee has completed a Certification of Tax-Qualified Dependents, then the
Employee may receive reimbursements of their expenses from the Employee's flexible spending account.
However, if the Civil Union Partner and his/her children are not the Employee's tax dependents, their
expenses are not eligible for reimbursement from the Employee's flexible spending account.
Benefits relating to the Civil Union Partner and his/her children under dependent care spending accounts
will depend on how the Civil Union Partner and/or his or her children fit within the guidelines established
by the tax code for these benefits.
COBRA
While continuation of medical, dental and voluntary vision coverage is not required under federal COBRA
laws, such coverage is allowed under the same terms that would apply to an Employee's spouse and
children. A Civil Union Partner and/or children of the Civil Union Partner enrolled in medical, dental and
voluntary vision plans have 60 days from the date that eligibility for coverage ends to enroll in COBRA
coverage.
Tax Effect
IRS regulations require the employer to tax the Employee for the excess of the fair market value of
coverage provided to the Civil Union Partner and his/her children over the amount the Employee pays, if
any, for the coverage. In general, an Employee’s premiums for coverage of a Civil Union Partner or
dependent of a Civil Union Partner are paid on an after-tax basis. There is an exception to this rule if the
Civil Union Partner and his/her children are tax dependents for medical, dental and term life plan
purposes. Please review the document titled, "Important Tax Information for Partners in a Civil Union –
Medical, Dental and Term Life Benefits", and complete the Certification of Tax-Qualified Dependents, if
appropriate.

Required Dependent Eligibility Documentation
Registered copy of marriage certificate
AND
Legal Spouse
A document dated within the last 60 days showing current relationship status,
such as a monthly or quarterly household bill or statement of account. The
document must list your spouse’s name, the date and your mailing address OR
the first page and signature page of your most recent federal tax return.
Common-law marriage affidavit
AND
Common-Law Spouse
A document dated within the last 60 days showing current relationship status,
such as a monthly or quarterly household bill or statement of account. The
document must list your spouse’s name, the date and your mailing address.
Registered copy of civil union certificate.
AND
Civil Union
A document dated within the last 60 days showing current relationship status,
such as a monthly or quarterly household bill or statement of account. The
document must list your partner’s name, the date and your mailing address.
The child’s birth or adoption certificate, naming you or your spouse as the
child’s parent, or appropriate custody or allocation of parental responsibility
Children
documents naming you or your spouse as the responsible party to provide
insurance for the child.
Newborns – The registered birth certificate must be provided within 31 days of
birth. Social Security number must be provided within 90 days of birth.



-3-

BENEFIT ELIGIBILITY

The eligibility documentation must be provided within the following timeframes:
Within 31 days of benefits eligibility, or
During the annual Open Enrollment period as scheduled by the member institutions for benefit changes
effective the following January 1st, or
Within 31 days of all changes related to IRS-defined change of status

The employee must provide a certified and notarized translation of any documents presented which are in a
foreign language.

Participant
“Participant” means an Eligible Employee, Dependent or Beneficiary who satisfies the requirements for
participating in any Benefit Plan offered under the Trust, and includes any former Employee, former
Dependent, qualified Beneficiary whose coverage under any Benefits Plan is continued or extended in
accordance with the provisions of the Benefit Plan and Trust.
Enrollment
Eligible Employees must complete and file an enrollment application within 31 days of their first day of
employment and authorize payroll deductions for the coverage elected. For eligibility, please contact your
Human Resources/Benefits Office. Eligible Employees may waive medical and dental coverage if they
submit evidence of coverage under another group health plan and submit a signed waiver form during
initial or annual enrollment. If coverage under the Medical and Dental Benefits Plans is waived, Dependent
coverage must also be waived. If coverage is waived, Eligible Employees and their Dependents may enroll in
coverage under a Benefits Plan only during the next annual open enrollment or within 31 days of a
qualifying event under IRC section 9801. Individual or family coverage through the Health Insurance
Marketplace is not group health insurance and does not qualify for a waiver of medical and dental coverage.
NOTE: Employees must enroll in both Medical and Dental coverage. If an employee waives Medical insurance, Dental insurance must also be waived. Coverage
may be waived due to religious affiliation. Employees must enroll in Basic Term Life, Accidental Death and Dismemberment and Long-Term Disability coverages.
These insurance coverages may not be waived. All waiver and enrollment requests must be approved by your Human Resources/Benefits Office.
Premium Payments
To assist in reducing your insurance premium costs, your share of medical, dental and vision insurance
premiums can be paid with pre-tax dollars under the CHEIBA Section 125 Plan. For Premium Payments
involving Civil Union Partners and the children of Civil Union Partners, please review the document titled,
“Important Tax Information for Partners in a Civil Union – Medical, Dental and Term Life Benefits”.

PERA Participants
If you are a Participant in PERA and are within three years of retirement, you may want to elect to pay
your premiums with after-tax dollars to ensure your highest possible PERA benefit in retirement. PERA
retirement benefits are based on your highest average salary. Please contact your Human
Resources/Benefits Office for additional information.
Default Medical and Dental Coverage
If an Eligible Employee does not complete and file an enrollment application or waiver form within 31 days
of the first day of employment, the Employee will automatically be enrolled in the medical benefits Blue
Priority (PPO) Plan option and Anthem Blue Dental PPO Plus plan. Contributions will be deducted from the
Employee’s payroll on an after-tax basis as a condition of employment if the Employer requires Employee
contributions. Changes to default coverage are only permitted during the annual open enrollment and
within 31 days of a qualifying status change.
Annual Open Enrollment
Each fall the CHEIBA Trust and the CHEIBA Trust Members announce an annual open enrollment period,
during which time Eligible Employees may make certain coverage changes. During open enrollment,
Employees may add or delete Eligible Dependents from coverage under the Plan. Employees and qualified
beneficiaries may add dependents only during open enrollment or during “special enrollment and qualifying
status changes” described later in this summary.
-4-

BENEFIT ELIGIBILITY CHANGES


CHANGING ELECTIONS DURING THE PLAN YEAR
After your institution’s annual open enrollment period is closed, you may change your benefits election
during the Plan Year only after a qualifying status change. Within 31 days of a qualifying status change, you
must submit a written request to your Human Resources/Benefits Office specifying the change you are
seeking. Upon approval of the change by your Human Resources/ Benefits Office, the election change is
then completed by you on a new Employee Election Form. This approved election change will continue until
another eligible event occurs or until you change your election during the next annual open enrollment
period.

Eligible Events that May Allow Election Changes
All changes requested after open enrollment must be approved by the Human Resources/Benefits Office.
Requested changes must be on account of and corresponding with a qualifying status change that affects
eligibility for coverage under an employer’s plan. Employee’s transferring from one CHEIBA Trust institution
to another may or may not be eligible for a plan change. See your Human Resources/Benefits Office for
more details if you believe this applies to you.

Election changes must be requested within 31 days of the qualifying status change event. Changes allowed
under federal regulations must fit within one of these categories: HIPAA, FMLA, COBRA or Qualifying Status
Change (see the following definitions).

Health Insurance Portability and Accountability Act (HIPAA)
Special enrollment provisions may allow you to enroll or add Dependents during the Plan Year. This
option applies only to insurance coverage changes. Special enrollment is only permitted if you properly
waive coverage because you have other coverage and your other coverage involuntarily terminates.
Special enrollment is also permitted when an Employee who was previously not enrolled marries or has a
new child. You must request special enrollment in writing within 31 days of the event.
NOTE: A newborn child born to the Subscriber or Subscriber’s Spouse is covered under the Subscriber’s coverage for the first 31 days after birth.
To continue the newborn child’s participation in the coverage beyond the 31-day period after the newborn child’s birth, the Subscriber must
complete and submit an Enrollment Application and Change Form within 31 days after the birth of the child to add the newborn child as a
Dependent child to the Subscriber’s policy.

Terminating Coverage
When you or a covered Dependent terminates coverage under the medical plan, you may request that
the medical plan send you a certificate of coverage that identifies the length of coverage under the plan.
The HIPAA Certificate of Coverage may be needed for you to enroll in another medical plan. If you are
eligible for Medicare and did not enroll in the Medicare drug card program, Medicare Part D, during the
initial open enrollment in October 2016, you are also entitled to a notice of creditable prescription drug
coverage. You will need this notice to later enroll in Medicare Part D without penalty.


Protected Health Information
The CHEIBA Trust will not use or further disclose Protected Health Information (PHI) in a manner that
would violate the requirements of state or federal law or regulation. The CHEIBA Trust and the CHEIBA
Trust Members will use PHI to the extent of and in accordance with the uses and disclosures permitted
by HIPAA.




-5-

BENEFIT ELIGIBILITY CHANGES



Qualifying Status Changes
You are only allowed to change your election during a Plan Year, if certain life changes occur. Any
approved election change must be on account of and corresponding with a qualifying change in status
that affects eligibility for coverage under an employer’s plan.

Eligible changes listed under IRS regulations include the following status changes:
change in Employee’s marital status; marriage, divorce, annulment, legal separation or death of a
spouse;
change in number of tax-eligible Dependents; birth, adoption, placement for adoption, court
ordered change in legal custody status or Qualified Medical Child Support Order (QMCSO) or
death of a Dependent;
change in employment status: transition from full-time to part-time, part-time to full-time, strike
or lockout, affecting an Employee, Employee’s spouse or Eligible Dependent;
commencement of/or return from an unpaid leave of absence Family Medical Leave Act (FMLA)
or other approved unpaid leave of absence by an Employee, Employee’s spouse or Eligible
Dependent;
commencement or termination of employment by an Employee, Employee’s spouse or Eligible
Dependent;
attainment or loss of Dependent eligibility as defined by the Plan, i.e., exceeding the Plan’s
established age limitations or eligibility for coverage under another health plan would all qualify
as an eligible change in status events;
entitlement to/or loss of Medicaid or Medicare coverage by an Employee, Employee’s spouse or
Eligible Dependent;
residence and/or worksite change: a required change in place of residence and/or work site of an
Employee, Employee’s spouse or Eligible Dependent, i.e., a move outside a health plan’s service
area would qualify as a change in status event;
an Employee may revoke his/her election or make a prospective election change during the Plan
Year if the change corresponds with an open enrollment period change made by the Employee’s
spouse or Eligible Dependent, provided that the election change is consistent with the changes
under the group plan; or
significant change in available benefits and/or their costs, i.e., if a fully insured health plan
imposed a change in benefit coverage levels or increases premiums substantially, this would
qualify as a change in status event. NOTE: This does not allow election changes in the Health
Care Spending Account.
Other eligible changes include the establishment of a civil union and the termination or
dissolution of the civil union.



NOTE: See your Human Resources/Benefits Office to request a change during the Plan Year and to help you

determine if an election change is allowed based on your individual situation.



-6-

BENEFIT ELIGIBILITY TERMINATION

TERMINATION OF ELIGIBILITY
Eligibility to participate in the Benefit Plans under the Trust shall terminate on the earliest of the following
dates:
The last day of the month in which an Employee terminates employment for any reason including death
and retirement or the last day of the month following the month in which an Employee terminates
employment for any reason including death and retirement,
The last day of the month in which an Employee ceases to satisfy the definition of an Eligible Employee
either because of a change in status or a reduction in the scheduled work hours per week falls below the
minimum number of hours required for coverage under the Trust,
The last day of the month for which contributions are paid in a timely manner,
The date the Trust or any Benefit Plan under the Trust is terminated or amended to terminate benefits
for any class of Participants,
The effective date an Employee elects to waive coverage under any Benefit Plan,
The date a Participant enters the armed forces of any country on active full-time duty,
The date any certificate of insurance coverage issued under any Benefit Plan is terminated or amended
to terminate coverage for any Participant, or
The date a Participant falsifies or misuses documents or information relating to coverage or services
under any Benefit Plan or any certificate.

Dependent coverage terminates on the earliest of the date coverage would otherwise terminate above, and
the following:
The date a Dependent enters the armed forces of any country on active full-time duty,
The last day of the month in which the Dependent ceases to satisfy the definition of a Dependent under
the Trust, any Benefit Plan under the Trust or any certificate of insurance coverage,
The last day of the month a Dependent child turns age 26.

Leaves of Absence
Coverage under the Plan may continue for certain Employees on an Approved Leave of Absence, including
but not limited to:
Short Term Disability/Long Term Disability
Workers Compensation Leave
Family and Medical Leave Act
Military Leave under the “Uniformed Services Employment and Reemployment Rights Act”




-7-

BENEFIT HIGHLIGHTS


Assignment and Payment of Benefits
No benefit payable under the Plan can be assigned, transferred or subject to any lien, garnishment, pledge
or bankruptcy. However, a Participant may assign benefits payable under this Plan to a provider or hospital
pursuant to the term of the certificate. Ultimately, it is the Participant’s responsibility to pay any hospital or
provider. If the benefit payment is made directly to a Participant, for whatever reason, such payment shall
completely discharge all liability of the Plan, the CHEIBA Trust Committee and the Employer.
If any benefit under this Plan is erroneously paid to a Participant, the Participant must refund any
overpayment back to the Plan. The refund may be payment, reduction of future benefits otherwise payable
under the Plan, or any other method as the CHEIBA Trust Committee in its sole discretion, may require.

Right to Information and Fraudulent Claims
The CHEIBA Trust Committee has the right to request information from any Participant to verify his/her and
Dependent eligibility and entitlement to benefits under the Plan. If a Participant falsifies any document in
support of a claim or coverage under the Plan, the CHEIBA Trust Committee may, without the consent of
any person, terminate coverage and refuse to honor any claims under the Plan for the Participant and
Dependent, and the Participant may be liable to the CHEIBA Trust or his or her employer for all resulting
monetary damages, costs and attorneys' fees which result from such actions. In addition, the Employee
may be subject to disciplinary action, up to and including termination of employment.

Third Party Reimbursement and Subrogation
If you or a covered Dependent receive benefits under a CHEIBA Trust Plan for injury, sickness or disability
that was caused by a third party, and you have a right to receive a payment from the third party, then the
CHEIBA Trust has the right to recover payments for the benefits paid by the CHEIBA Trust Plans. If you
recover any amount for covered expenses from a third party, the amount of benefits paid by the CHEIBA
Trust Plans will be reduced by the amount you recover.

In making a claim for benefits from the CHEIBA Trust Plans, you and your covered Dependents agree that
the CHEIBA Trust will be subrogated to any recovery, or right of recovery, you or your Dependent has
against any third party, and that the CHEIBA Trust will be reimbursed and will recover 100% of any amount
paid by the CHEIBA Trust Plans or amounts which the Plans are otherwise obligated to pay. You also agree
that you will not take any action that would prejudice the CHEIBA Trust’s subrogation rights and will
cooperate in doing what is reasonably necessary to assist the CHEIBA Trust in any recovery. The CHEIBA
Trust has a right to pursue all legal and equitable remedies to recover, without deduction for attorney’s fees
and costs or other expenses you incur, and without regard to whether you or a covered Dependent is fully
compensated by the recovery or made whole. The Plan’s right of recovery and reimbursement is a first
priority and first lien against any settlement, judgment, award or other payment obtained by you or your
Dependents, for recovery of amounts paid by the CHEIBA Trust Plans.










- 8 -

BENEFIT HIGHLIGHTS




Medical


Travel
Dental

Accident



Long Term

Benefit
Vision
Disability


Plan

Choices

Flexible
Basic Term

Benefit Plan
Life


Voluntary
Voluntary

Employee
Employee

Paid AD&D
Paid Life



MEDICAL INSURANCE
Anthem Blue Cross and Blue Shield
You select your medical plan coverage during open enrollment or when you become a new benefit-eligible
Employee. Four (4) Options are available: BlueAdvantage Point of Service Plan (HMO/POS), PRIME Blue Priority
PPO, Blue Priority HMO Plan and Lumenos High Deductible Health Plan (HSA Compatible).

DENTAL INSURANCE
Anthem Blue Cross and Blue Shield
You select your dental plan coverage during open enrollment or when you become a new benefit-eligible
Employee. Two (2) options are available: Anthem Blue Dental PPO Plus or Anthem Blue Dental PPO

VISION INSURANCE
Anthem Blue View Vision
Your enrollment in any of the CHEIBA medical plans includes coverage for a routine eye exam (once every 12
months). You will need to elect coverage for eyewear materials and lens treatment option and this is a
voluntary Employee-paid option. LASIK discounts are included in this plan.
BASIC TERM LIFE INSURANCE
Anthem Life Insurance Company
Term Life and Accidental Death and Dismemberment coverage is provided as a basic plan. The basic
coverage is two times your annual base salary (until age 65) to a maximum of $500,000 in death benefits for
all benefit-eligible Employees. Review Anthem Basic Term Life Insurance section for details regarding basic
coverage for Employees 65 and older. There is Dependent life coverage included in the group life insurance
premium (see Basic Term Life Insurance section for details).


- 9 -

BENEFIT HIGHLIGHTS



VOLUNTARY EMPLOYEE-PAID TERM LIFE INSURANCE
Anthem Life Insurance Company
This plan is available for all benefit-eligible Employees, their spouses, Civil Union Partners and children. An
Employee can purchase coverage in $10,000 increments to a maximum of $300,000 in death benefits for
yourself, your spouse, or your Civil Union Partner. Eligible Dependent children can be covered to a
maximum of $5,000 per child. (Restrictions apply. See Voluntary Term Life Insurance chapter for details).

VOLUNTARY EMPLOYEE-PAID ACCIDENTAL DEATH & DISMEMBERMENT INSURANCE
Mutual of Omaha Insurance Company
Accidental Death and Dismemberment Insurance can be purchased as an Employee Only Plan or an
Employee and Family Plan. Coverage for you is available to a maximum of $500,000. Under the Family Plan,
the benefit amount to your spouse or Civil Union Partner will be 50% of yours and each eligible child’s
benefit amount will be 10% of yours.

FLEXIBLE BENEFIT PLAN
24HourFlex (Except Fort Lewis College)
The colleges, universities and institutions of higher education participating in the CHEIBA Trust offer a
Flexible Benefit Plan under Section 125 of the Internal Revenue Code. There are three separate and
optional components under the Plan: Pre-Tax Insurance Premium Payments, Health Care Spending Account,
and Dependent Care Spending Account. These options provide you with the opportunity to pay some of
your insurance premiums and other eligible family expenses with pre-tax dollars. Once selected, the Pre-
Tax Insurance Premium Payment option will continue until a waiver is signed during open enrollment or as
the result of a qualifying status change. Employees must re-enroll in the Health Care Spending Account and
the Dependent Care Spending Account during open enrollment each year, or enroll as a new benefit-eligible
Employee. The Spending Accounts are administered by 24HourFlex (except Fort Lewis College).

LONG-TERM DISABILITY INSURANCE
Standard Insurance
Should you experience a long-term disability, the plan will replace a portion of your income. You are eligible
for benefits after you have been disabled for 90 days.

TRAVEL ACCIDENT INSURANCE
CHUBB
This employer-paid insurance provides protection should you be seriously injured or die during employer-
approved work-related travel (i.e. conferences, seminars and workshops etc.).

PARTICIPANT ADVOCATE LINK “P.A.L.”
You have a P.A.L.! This service is provided by the CHEIBA Trust (at no cost to you) to assist you in resolving
benefit issues that you have been unable to resolve on your own. Your P.A.L. is an independent consultant
located at Arthur J. Gallagher & Co., the full-service benefit consulting firm for the CHEIBA Trust. If you have
billing problems with your doctor or hospital, a claim or service denied in error, reimbursement problems,
trouble seeing a specialist, disability insurance or life insurance problems, call your P.A.L. directly at 303-
889-2692 or 1-800-943-0650; Monday through Friday from 8:00 a.m. to 4:00 p.m. When you call, have your
Member ID number, name of the college or agency and other relevant information available (i.e. name of
insurance company, group number, date of service, physician or hospital name, bills or letters from the
insurance company).
- 10 -

MEDICAL INSURANCE




The CHEIBA Trust and the CHEIBA Trust Members offer you four medical insurance
plans from which to select. Please carefully review the Multi-Option Plan
Summary located in the pocket of this booklet regarding the various medical
insurance plans before you make your selection. After you enroll, you will receive
your membership card. It will be mailed to your home. If you do not receive your

card, call the Customer Service number as noted on the Plan Contacts Page at the

beginning of this book.



ANTHEM BLUE CROSS AND BLUE SHIELD/HMO COLORADO

Your choices include:





BlueAdvantage
Prime Blue

Point of
Priority PPO

Service Plan
Plan







Lumenos High
Blue Priority

Deductible
HMO Plan

Health Plan






- 11 -

MEDICAL INSURANCE



BlueAdvantage
PRIME Blue Priority PPO
Blue Priority HMO
Lumenos PPO
Description
In Network
Out of Network (POS)
PPO In Network
Non-PPO Out of Network
HMO In Network Only
PPO In Network
Non PPO Out of Network
(HMO)
Grandfathered Health Plan
NO
NO
NO
NO

You Pay
You Pay




$500 Individual
$400 Individual
$1,000 Individual
$2,500 Individual
$2,500 Individual
Annual Deductible
None
$2,000 Individual
$1,000 Family
$800 Family
$2,000 Family
$5,000 Family
$5,000 Family
$6,000 Family
Out-of-Pocket Annual
$2,000 Individual
$3,000 Individual
$2,000 Individual
$4,000 Individual
$4,000 Individual
$2,500 Individual
$5,000 Individual
Maximum
$4,000 Family
$6,000 Family
$4,000 Family
$8,000 Family
$10,000 Family
$5,000 Family
$10,000 Family
Al copayments (including Rx
Al copayments (including Rx
Out of Pocket Annual
Al copayments (including Rx
Deductible, Coinsurance
copayments), Deductible and
Deductible & Coinsurance
copayments), deductible and
Deductible
Deductible & Coinsurance
Maximum Includes
copayments)
Coinsurance
coinsurance
Physician Selection
PCP required
Unrestricted
PCP required
Unrestricted
PCP required
Unrestricted
Unrestricted
Medical Office Visits

$10 copayment for Designated Provider

Preventive Care Covered 100%


Primary Care
$20 copayment per visit
30% after deductible
(Primary/Specialist) / 15% after
$20 copayment per visit
0% after deductible
30% after deductible

35% after deductible
Specialist
$40 copayment per visit
deductible for Participating Providers
$60 copayment per visit
0% after deductible
LiveHealth Online
$20 copayment per visit
Not Covered
$10 copayment per visit
Not Covered
$20 copayment per visit
0% after deductible
30% after deductible
(Telemedicine)
Urgent Care
$50 copayment per visit
$50 copayment per visit
15% after deductible
35% after deductible
$60 copayment per visit
0% after deductible
30% after deductible
Emergency Room
$150 copayment per visit
$150 copayment per visit
15% after deductible
15% after deductible
$250 copayment per visit
0% after deductible

$250 copayment + 20% after
Inpatient Hospital
$600 copayment per admission
30% after deductible
15% after deductible
35% after deductible
0% after deductible
30% after deductible
deductible
Outpatient Surgery


$250 copayment + 20% after



Hospital Based Facility
$125 copayment per visit
15% after deductible
deductible (Hospital)
0% after deductible
30% after deductible

30% after deductible
35% after deductible
Freestanding Facility
$60 copayment per visit
10% after deductible
$250 copayment (Freestanding)
Labs covered 100% /X-Ray $60
10% after deductible (Freestanding)
copayment (Freestanding)
Outpatient Lab & X-Ray
Covered 100%
30% after deductible
35% after deductible
0% after deductible
30% after deductible
15% after deductible (Hospital Based)
$250 copayment + 20% after
deductible (Hospital)
Advanced Imaging


$250 copayment + 20% after
(MRI/MRA/PET/CT Scans)




15% after deductible
deductible
0% after deductible
30% after deductible
Hospital Based Facility
$120 copayment per procedure
30% after deductible
35% after deductible

10% after deductible
$250 copayment per procedure
Freestanding Facility
$60 copayment per procedure
Drug Formulary
Essential Drug Formulary
Essential Drug Formulary
Essential Drug Formulary
Essential Drug Formulary
$200 Individual / $400 Family Deductible 2



Prescriptions Retail
Tier 1-$10 copayment
Tier 1-$10 copayment
Not Covered
Not Covered
Tier 1-$15 copayment
0% after deductible
30% after deductible
(30-day supply)
Tier 2-$40 copayment
Tier 2-$40 copayment
Tier 2-$40 copayment
Tier 3-$60 copayment
Tier 3-$60 copayment
Tier 3-$60 copayment
Tier 1-$10 copayment
Tier 1-$10 copayment
Tier 1-$15 copayment
Prescriptions Mail Order
Tier 2-$80 copayment
Not Covered
Tier 2-$80 copayment
Not Covered
Tier 2-$80 copayment
0% after deductible
Not covered
(90-day supply)
Tier 3-$120 copayment
Tier 3-$120 copayment
Tier 3-$120 copayment
Specialty Drugs ¹ (Tier 4)
30% coinsurance to max $125
Not Covered
30% coinsurance to max $250
Not Covered
30% coinsurance to max $250
0% after deductible
Not covered
(30-day supply)
¹ Not all specialty drugs on Tier 4 are subject to the Tier 4 coinsurance. Certain specialty drugs may be subject to the Tier 1, 2 or 3 copayment.
₂ Tier 2 and Tier 3 retail pharmacy, specialty pharmacy and/or home delivery drugs are first subject to a deductible. Once satisfied, then services are subject to the applicable copayment per prescription.
- 12 -

MEDICAL INSURANCE

PRESCRIPTION DRUG BENEFIT
Prescription drug coverage is included with all medical plans. Your
prescription drug coverage has three copayment tiers, with generic
medications having the lowest copayments. You can save more on
medications you take regularly, sometimes called maintenance medications,

by using the mail order pro

gram.

Your plans use a drug list called a formulary to help determine your copayment for each prescription. The drugs on your formulary were
selected to give you the highest level of coverage under your prescription drug benefit.

What is the Essential Drug List?
The Essential Drug List is a list of brand-name and generic prescription medications that have been selected and are periodically
reviewed through Anthem’s Pharmacy & Therapeutics process for proven effectiveness, high quality, and affordability. The Essential
Drug List includes all of the essentials, but is a focused list that offers pharmacy cost savings while ensuring there are no gaps in care.

What can a member do if their medication isn’t on the Essential Drug List?
If your medication is not on the Essential Drug List, there may be a brand alternative, a generic equivalent or OTC option. When you
search the Essential Drug List, you will see the generic equivalent if available; however, OTC options will not be displayed. If an
alternative isn’t listed, members should talk with their doctor or pharmacist about whether another medication that is included on the
Essential Drug List or an OTC may be right for them.
Non-formulary medications can be requested through the formulary exception process. If a medication a member takes isn’t covered on
the Essential Drug List, the member or doctor can ask us to keep covering it by asking for a formulary exception. The process is the
same as any Prior Authorization request. The member or doctor can call Member Services at the number on the ID card. Members can
also go online to find the preapproval fax form to ask for a formulary exception. In most cases, the prescribing doctor is first asked
whether the member has tried two formulary alternatives. If not appropriate or available, Anthem will review the clinical requirements and
concerns presented by the doctor. For some classes and most specialty medications, drug-specific prior authorization criteria may be
used. This is done to ensure specific alternatives are tried or the medication is used for the correct indication.

How can I search the Essential Drug List?
At www.anthem.com/pharmacyinformation select the Essential 4-tier Drug List. You can search for medications, and see which drugs are
covered and at what tier level. You can enter the name of the drug or you can browse through the categories shown on the screen. Once
you are on the drug details page, you’ll see the tier level listed. If you see “NF” that means the drug is non- formulary and not covered.
- 13 -

MEDICAL INSURANCE

PRESCRIPTION DRUG BENEFIT

Blue Advantage HMO/POS, Prime Blue Priority PPO, Blue Priority HMO and Lumenos HDHP
Your ID Card is your membership card for both doctor visits and prescriptions. The prescription drug benefit is provided through Anthem's
Pharmacy Benefits Manager (PBM) and includes a formulary plan with four tiers:

Tier 1 Generics - these drugs are simply copies of brand-name drugs. Brand-name and generic drugs have the same active ingredients,
strength and dose. The FDA requires that generic drugs meet the same high standards for purity, quality, safety and strength. With
generics, you get the same quality for less money.
Tier 2 Preferred Brand - these are drugs for which generic equivalents are not available. They have been in the market for a time and are
widely accepted. They cost more than generics, but less than non-preferred brand-name drugs.
Tier 3 Non-Preferred Brand - these drugs are generally higher-cost medications that have recently come on the market. In most cases,
an alternative preferred or generic medication is available.
Tier 4 Specialty Drugs - these are prescription medications used to treat complex, chronic conditions that may require special handling
and/or management. It is important to note the following:

o Not all specialty drugs on Tier 4 are subject to the Tier 4 coinsurance. For example, capecitabine, a drug used to treat cancer, is
generic so a member could obtain this prescription for the Tier 1 copayment.

o Some specialty drugs are considered Retail Pharmacy Drugs and are not on the Exclusive Specialty List. These drugs are not
required to be obtained through the specialty pharmacy. An example of this would be Arixtra, a drug used to prevent blood clots.
The formulary includes prescription drugs that have been approved for use by HMO Colorado and is updated on a quarterly basis. You can review
this formulary by going to www.anthem.com.


NOTE: Prescription drugs will always be dispensed as ordered by your provider and by applicable State Pharmacy Regulations, however,
you may have higher out-of-pocket expenses. You may request, or your provider may order, the brand-name drug. However, if a generic
drug is available, you will be responsible for the cost difference between the generic and brand-name drug, in addition to your Tier
copayment. The cost difference between the generic and brand-name drug does not contribute to the out-of-pocket annual maximum. (Tier
1 generic copayment is not applicable if you are enrolled in the Lumenos HDHP)
Diabetic supplies/prescriptions and asthma inhalers/prescriptions will be covered at no cost to you.
Members taking specialty drugs must order them through Accredo at 1-800-870-6419, which offers a full-service pharmacy that ships
medications to members or their provider, up to a 30-day supply, by overnight mail or common carrier.
Mail Order/Home Delivery: If you need maintenance medications for ongoing conditions such as asthma, diabetes, high blood pressure, etc., you
may want to use home delivery service. This service offers you the convenience of having prescriptions delivered directly to the home, office or
anywhere in the United States. Ordering your maintenance medications through home delivery eliminates monthly trips to the pharmacy and allows
you to receive more days’ supply with fewer copayments. Typical savings are at least one copayment for each prescription.

Prescription drugs purchased from out-of-network pharmacies are not covered.


Call Customer Service at: ...................... 1-800-542-9402
If you have questions
or
Go to the website: ............................ www.anthem.com



- 14 -

MEDICAL INSURANCE

BLUE ADVANTAGE HMO/POS
The Point-of-Service (HMO/POS) Plan includes both in-network and out-of-network benefits. A member has the option for both in-network and out-
of-network benefits based on the provider rendering the service.

Services rendered by a non-HMO provider are processed under the POS benefits and are subject to the applicable deductible and coinsurance.
This option is designed to give HMO members the choice to use a non-HMO provider and still receive a level of benefits. A referral from your HMO
primary care provider is not needed to seek services from a non-HMO provider.

Additionally, out-of-network services may be subject to Balance Billing. If you have any questions regarding out-of-network services, please read
the plan description carefully or call for assistance.

PHYSICIAN SELECTION
You must select a primary care physician (PCP) for yourself and each covered Dependent in order to be eligible for in-network benefits. You have
the right to designate any primary care provider who participates in the network and who is available to accept you or your family members. For
children, you may designate a pediatrician as the primary care provider. Members are not required to obtain a referral from their PCP to see an in-
network specialist. However, Anthem does encourage you to ask your PCP for an in-network referral recommendation.

To search for primary care providers and participating health care professionals online, please visit www.anthem.com:
 Select Find A Doctor

Select Search by selecting plan or network

Select a state: (choose from drop down menu)

Select a plan/network (Medical Network): HMO

Choose Select and Continue

Complete fields for provider type, specialty and location
 Select: Search
PRIME BLUE PRIORITY PPO
This choice provides a flexible plan option that allows you access to three different levels of providers, each with different out-of-pocket costs:
Level 1: Blue Priority Designated providers are either PCP’s or specialists. A Designated PCP or Designated specialist has the lowest out-of-
pocket costs with a simple co-pay. Blue Priority Designated providers are located in the following counties: Adams, Arapahoe, Boulder
(including Longmont), Broomfield, Denver, Douglas, Elbert, El Paso, Fremont, Jefferson, La Plata, Montezuma, Pueblo, Summit and Teller.
Level 2: Providers in Anthem’s large, traditional PPO network may serve as PCP’s and specialists.
Level 3: Nonparticipating providers have the highest out-of-pocket costs.
Additionally, out-of-network services may be subject to Balance Billing. If you have any questions regarding out-of-network services, please read
the plan description carefully or call for assistance.
NOTE: If you live in a rural area and there are no PPO providers within a reasonable distance from you, you may request an authorization to see an out-of-
network provider. If approved, benefits will be applied at the in-network level. Please contact Anthem Blue Cross Blue Shield at 1-800-542-9402 for assistance.

PHYSICIAN SELECTION
You must select a Blue Priority Designated primary care physician (PCP) for yourself and each covered Dependent. However, you may receive care
from any provider that participates in the network. You will pay less if you receive care from a Designated provider.
Members are not required to obtain referrals from their PCP to see an in-network specialist. . However, Anthem does encourage you to ask your
PCP for an in-network referral recommendation.

To search for primary care providers and participating health care professionals online, please visit www.anthem.com:


Select Find A Doctor

Select Search by selecting plan or network

Select a state: (choose from drop down menu)

Select a plan/network (Medical Network): PPO (Level 2 & 3 providers) / For Designated Blue Priority (Level 1) providers, please select the
Blue Priority PPO

Choose Select and Continue

Complete fields for provider type, specialty and location
 Select: Search


- 15 -

MEDICAL INSURANCE

BLUE PRIORITY HMO
The Blue Priority HMO Plan includes in-network benefits only.
Members must choose a primary care physician from the Blue Priority network. Providers are located in the Denver metro area, which includes
Adams, Arapahoe, Boulder, Broomfield, Denver, Douglas and Jefferson counties, as well as Elbert, El Paso, Teller, Fremont, La Plata, Montezuma,
Pueblo, Summit counties and the city of Longmont.
PHYSICIAN SELECTION
You must select a primary care physician (PCP) for yourself and each covered Dependent in order to be eligible for in-network benefits. You have
the right to designate any primary care provider who participates in the network and who is available to accept you or your family members. For
children, you may designate a pediatrician as the primary care provider.
Your primary care physician is your personal provider who coordinates your care within the Blue Priority HMO network. Referrals to see a
specialist are required.
To search for primary care providers and participating health care professionals online, please visit www.anthem.com:
 Select Find A Doctor

Select Search by selecting plan or network

Select a state: (choose from drop down menu)

Select a plan/network (Medical Network): Blue Priority HMO

Choose Select and Continue

Complete fields for provider type, specialty and location
 Select: Search
LUMENOS HIGH DEDUCTIBLE HEALTH PLAN
This choice is a High Deductible Preferred Provider (PPO) plan option which includes in and out-of-network coverage.

Members must pay their annual deductible¹ during the plan year before the plan helps pay for costs. This includes costs for medical and prescription
drug expenses. All in-network preventive care services are 100% covered.
In-network doctors have a pre-negotiated rate with Anthem Lumenos, so your expenses will be less if you use in-network doctors.
Example: If you go to a doctor for a sore throat before you meet the deductible, you pay the full (negotiated) cost of the office visit and any tests your physician
orders and prescription drugs prescribed.

This plan can be combined with a health savings account (HSA) to allow you to pay for qualified, out-of-pocket medical expenses on a pre-tax basis.
An HSA account is a personal, portable account and remains in your control regardless of your employment. An HSA can be established through
any qualifying financial institution. Please contact your financial advisor or banking institution for additional information.
¹ The annual deductible under the Lumenos HDHP is non-embedded. For employees with dependents, this means that all family members’ out-of-pocket
expenses count toward the family deductible until it is met. It does not matter if one person incurs all the expenses that meet the deductible or if two or
more family members contribute toward meeting the family deductible.

PHYSICIAN SELECTION
You can select PPO physicians who have entered into an agreement with Anthem Blue Cross and Blue Shield to provide care at negotiated rates, or
you may select the physician of your choice outside of the PPO network. However, out-of-pocket expenses may be significantly higher if you select
an out-of-network provider.

To search for primary care providers and participating health care professionals online, please visit www.anthem.com:


Select Find A Doctor

Select Search by selecting plan or network

Select a state: (choose from drop down menu)

Select a plan/network (Medical Network): Lumenos PPO

Choose Select and Continue

Complete fields for provider type, specialty and location
 Select: Search
- 16 -

MEDICAL INSURANCE


CUSTOM PLUS HEALTH PLAN


Closed to new enrollment effective January 1, 2010.

This is a traditional major medical plan.

Physician Selection
There are no restrictions regarding the choice of physicians under this plan. Please note, if you select a provider
not participating in the Traditional Participating Network, you may be subject to Balance Billing.

Prescription Drug Benefit
Prescription drugs are covered at 80% after the deductible is met. There is no separate prescription card.
Prescription benefits are reimbursed to you after you submit a medical expense claim form found on
www.anthem.com. Claim forms are provided through Anthem Blue Cross and Blue Shield of Colorado or through
your Human Resources/Benefits Office.
Medical Benefits
Custom Plus
Description
No Defined Network
$800 Individual
Annual Deductible
$1,600 Family
$3,800 Individual
Annual Maximum Out-of-Pocket
$7,600 Family
Unrestricted; greater benefits with Traditional Participating Network
Physician Selection
provider
Physician Services
80% after deductible (based on the maximum benefit allowance)
Hospital
80% after deductible (based on the maximum benefit allowance)
Outpatient Surgery
80% after deductible (based on the maximum benefit allowance)
Outpatient Lab
80% after deductible (based on the maximum benefit allowance)
Prescriptions
80% after deductible
Retail & Mail Order

If you want to complete your enrollment forms, review the Multi-
Option Plan Summary or review this Benefit Booklet, reference
Custom Plus
this plan name:
If you want to search for information (like searching for a doctor)
Major Medical/ Traditional Provider Network
on the anthem.com website, reference this plan name:
Call Customer Service at: ...................... 1-800-542-9402
If you have questions
or
Go to the website: ............................ www.anthem.com






- 17 -

MEDICAL INSURANCE

MyAnthem™
Tired of paperwork and phone calls? Anthem offers its members a useful website. Register with anthem.com to
get online access to your benefits. MyAnthem™ takes the hassle out of your health care and allows you to get
your information when you need it. Use MyAnthem™ to:


Find a doctor

Search for a doctor, specialist, urgent care or hospital close by.




Get your ID card

Share, fax, or email your ID card.



Check your claims

Find out what your doctor billed, how much was paid and if you owe anything.



Estimate your costs

See what nearby doctors and facilities charge for a procedure. You can

compare providers on cost and quality.



View your medical benefits

See your copays, deductibles, your percentage of the costs, and other important plan

benefit information.



Manage prescription benefits

Check the cost of drugs, get refills or switch to our home delivery program.



Access your Health Record

View your Health Record and share with your doctors whenever you go.






DO YOU HAVE A SMARTPHONE?



Using Anthem’s free mobile app can make it easier than ever to manage your health care.

1. Go to the app store on your smartphone or mobile device.

2. Search for Anthem Anywhere

3. Select the app and start the free download.

To use the mobile application, you must be registered on Anthem’s secure member site

and have a username and password.



- 18 -

MEDICAL INSURANCE



- 19 -

MEDICAL INSURANCE

ConditionCare
If you or one of your dependents have diabetes, coronary artery disease (CAD), heart failure (HF), chronic obstructive
pulmonary disease (COPD) or asthma, ask Anthem about their programs to help manage these conditions. ConditionCare is
included in your health plans and offers valuable tools and information that could make a real difference as you strive for
better health.
 24-hour, toll-free access to registered nurses to answer your questions and provide you with support and education on
how to better manage your condition
 Specially designed condition-specific care diaries, self-monitoring charts, self-care tips and other easy-to-use
empowerment materials.
For information about Anthem’s ConditionCare programs, call toll-free 1-877-236-7486 or go to www.anthem.com and
select Health & Wellness. Various conditions are listed for your information.
Future Moms
The program, Future Moms, is there for our moms-to-be. At such an important time in your life, you’ll have access to extra
pre- and post-natal, confidential support and education any time of the day or night! Even with terrific care from your doctor,
you may have questions that come up between visits. Nurses are available for you to talk with around the clock. You may
also benefit from:
 Maternity care materials including Your Pregnancy Week By Week, which is a helpful prenatal care book, free for just
enrolling in the plan
 A confidential questionnaire to evaluate your risk for premature delivery
 Useful tools to help you, your doctor and your Future Moms nurse track your pregnancy and identify possible risks
Anthem’s goal is to help you and your doctor work together to have a healthy pregnancy and a healthy new baby. Remember,
your doctor is your best source of information about your pregnancy and your health, and Future Moms is here to help along
the way.
To reach Future Moms, call toll-free 1-800-828-5891 or go to www.anthem.com and select Health & Wellness
24/7 NurseLine
Whether it’s 3 p.m. or 3 a.m., wouldn’t it be great if you could speak with an experienced nurse about any of your health
questions or issues? Now you can!

The 24/7 NurseLine can assist you in making more informed health care decisions via confidential, one-on-one conversations
with a registered nurse, any time of the day or night. Whenever you call, you can easily access a library of audio tapes on a
range of topics related to your health care. Or, if you prefer, you can talk to a nurse about hundreds of health issues ranging
from asthma to zinc, like: Coughs Abdominal Pain Weight Loss Colds Children’s Health Sexually Transmitted Diseases.
Fever Food & Diet Headache Smoking Women’s Health . . . and much more! Bilingual nurses, the Language Line and
TTY/TDD relay services for the hearing impaired are also available.

For confidential health information from a registered nurse 24-hours a day, 365 days a year, call 1-800-337-4770 or go to
www.anthem.com and select Health & Wellness.

24/7 NurseLine is not an emergency response system. In a medical emergency, call 911 or your local emergency service
number.
To reach 24/7 NurseLine, call toll-free 1-800-337-4770 or go to www.anthem.com and select Health & Wellness.
Colorado QuitLine
Whether you are thinking about quitting tobacco or have already quit, Colorado QuitLine is a FREE program and here to help
you. Join QuitLine today and receive free:

 Personally tailored quit program
 Nicotine replacement therapy
 Support network
 Telephone coaching
 Tools and tips based on the latest research

Website:................................................................................................................................................ www.coquitline.org
Phone: ........................................................................................................................................................ 1-855-891-9988
- 20 -

MEDICAL INSURANCE

LIVEHEALTH ONLINE

What is LiveHealth Online®?
Use LiveHealth Online for common health concerns like colds, the flu,
fevers, rashes, infections, allergies and more! It’s faster, easier and more
convenient than a visit to an urgent care center.

LiveHealth Online is part of your health plan benefits. The cost of a LiveHealth Online visit is the same or less
than a primary care office visit. With LiveHealth Online, you have a doctor by your side 24/7. LiveHealth Online
lets you talk face-to-face with a doctor through your mobile device or a computer with a webcam. No
appointments, no driving and no waiting at an urgent care center.

How does LiveHealth Online work?
When you need to see a doctor, simply go to livehealthonline.com or access the LiveHealth Online mobile app.
Select the state you are located in and answer a few questions. Best of all, LiveHealth Online is a part of your
health plan. So, the cost of a LiveHealth Online visit is the same or less than a primary care office visit.
Establishing an account allows you to securely store your personal and health information. Plus, you can easily
connect with doctors in the future, share your health history and schedule online visits at times that fit your
schedule. Once connected, you can talk and interact with the doctor as if you were in a private exam room.

How do I access LiveHealth Online?
Sign up at www.LiveHealthOnline.com
or
Download the LiveHealth Online mobile app for free on your mobile device by visiting the App StoreSM or Google
PlayTM.

How do I pay for a LiveHealth Online session?
LiveHealth Online accepts Visa, MasterCard and Discover cards as payment for an online visit with a doctor.
Please keep in mind that charges for prescriptions aren’t included in the cost of your doctor’s visit.

Do doctors have access to my health information?
LiveHealth Online doctors can only access your health information and review previous treatment
recommendations and information from prior LiveHealth Online visits.
If you are using LiveHealth Online for the first time, you will be asked to answer a brief questionnaire about your
health before you speak with a doctor. Then the information from your first online visit will be available for
future LiveHealth Online visits.

Who do I get in touch with if I still have questions?
You can email, customersupport@livehealthonline.com or call toll free at 1-855-603-7985.

If you send us an email, please be sure to include:
Your name
Your email
A phone number where you can be reached

LiveHealth Online should not be used for emergency care. If you experience a medical emergency, call 911
immediately.



- 21 -

MEDICAL INSURANCE

LIVEHEALTH ONLINE PSYCHOLOGY

If you’re feeling stressed, worried or having a tough time, you may need someone to
speak with. Now you can see a licensed therapist using LiveHealth Online Psychology.
Talk with a therapist from your home or wherever you have internet access. It’s
quick, easy and private. Just download the free LiveHealth Online app to your mobile
device or visit www.livehealthonline.com on a computer with a webcam.

How do I schedule my first appointment with a psychologist or therapist using LiveHealth Online?
For your first visit, set up a time by going online, using the mobile app or calling LiveHealth Online:
Online: Visit www.livehealthonline.com and sign up or log in. Once you have logged in, select LiveHealth
Online Psychology. Next choose from available therapists after seeing their backgrounds and set up a visit.
Mobile App: Download the free LiveHealth Online mobile app and then sign up or log in. Once you have logged
in, select LiveHealth Online Psychology and choose an available therapist after checking out their qualifications
Phone: Call 1-844-784-8409 from 7 a.m. to 11 p.m.

In most cases, you can make an appointment to see a therapist within four days or less. LiveHealth Online will
send you an email confirming your appointment. You must be at least 18 years or older to visit with a therapist
online. Psychologists and therapists using LiveHealth Online Psychology do not prescribe medications.

How do I set up a follow up appointment?
At the end of your first visit, you can set up a future visit with the therapist if both of you feel it is needed. You
always have the choice of the therapist you would like to see.

How long does a visit usually last?
A typical visit with a psychologist or therapist using LiveHealth Online Psychology is about 45 minutes.

How do I pay for a LiveHealth Online session?
Depending on your coverage, the cost may be similar to what you would pay for an office visit, considering your
benefits, copay or coinsurance. You can pay your share of the visit using a Visa, Mastercard, Discover or American
Express credit or debit card. You will see what you owe before you start a visit and the cost is charged to your
credit card. The cost is the same no matter when you have the visit - whether it’s a weekday, the weekend,
evening or holiday.

What conditions can LiveHealth Online Psychology help with?
Therapists using LiveHealth Online can help you with stress, anxiety, depression, relationship or family issues,
grief, panic attacks and stress from coping with a sickness.

How do I know if a psychologist or therapist is in-network?
When you log in to www.livehealthonline.com, the providers you see on the website are part of the Anthem Blue
Cross and Blue Shield provider network. Make sure you select the state where you are currently located to view
the most up-to-date list of providers.

- 22 -

DENTAL INSURANCE

Strong teeth and gums are an important part of good health, which is why the CHEIBA Trust offers you and your eligible

dependents the choice of two comprehensive dental plans through Anthem.

Anthem Blue Dental PPO Plus
Anthem Blue Dental PPO
PLAN HIGHLIGHTS

In Network
Out of Network
In Network
Out of Network
Annual Maximum (per member)
$2,000
$2,000
$2,000
$2,000
Annual Deductible (individual/family)
$25 / $75
$25 / $75
$0
$50 / $150

Plan Pays
Plan Pays
Diagnostic & Preventive Services (deductible does not apply)
Diagnostic & Preventive services do not accumulate towards annual maximum
Services include:





Oral evaluations





X-Rays
100%
100%
100%
80%

Cleanings (Benefit includes (3) three annual cleanings for adults only)

Specified space maintainers
Restorative/General Services (deductible applies)




Services include:





Emergency palliative treatment
80%
80%
80%
60%

General anesthesia

Amalgam and anterior composite restorations
Endodontic Services (deductible applies)




Services include:
80%
80%
80%
60%

Root canal therapy
Oral Surgery Services (deductible applies)




Services include:
80%
80%
80%
60%

Simple and surgical tooth extractions
Periodontal Services (deductible applies)




Services include
80%
80%
80%
60%

Gingivectomy

Osseous surgery
Prosthodontic Services (deductible applies)




Services include





Crowns/onlays
50%
50%
50%
40%

Removable or fixed partials or dentures

Implants
Orthodontic Services





Adults
50% up to $1,500 ¹
50% up to $1,500 ¹
50% up to $1,500 ¹
40% up to $1,500 ¹

Children
50% up to $1,000 ¹
50% up to $1,000 ¹
50% up to $1,000 ¹
40% up to $1,000 ¹
¹ Lifetime Maximum – the cumulative dollar amount the plan will pay for orthodontic treatment incurred by an individual enrollee for the life of the plan. For family coverage, each individual covered under the plan is subject to the
lifetime maximum.

NOTE: This is only an overview of your dental plan choices. Review the specific dental brochures pertaining to each plan for further details and explanations. If discrepancies are found, depend upon the certificate of coverage
itself for accuracy.
- 23 -

DENTAL INSURANCE

Helpful Information to Help You Decide Which Plan/Network to Choose


Dental PPO
Dental PPO+
Number of In-Network
Access Points: over 4,300
Access Points: over 5,000
Providers
Unique Providers: over 1,700
Unique Providers: over 2,100
Access Points = the number of locations when Anthem has In-Network Providers.
Unique Providers = the number of individual providers in the network.

Both of your dental plan options are Preferred Provider Organizations (PPO) and offer you flexibility to
select the dentist of our choice or a dentist within the extensive Anthem dental network throughout
Colorado. While your dental plan lets you choose any dentist, you may end up paying more for a service if
Routine preventive care such as
regular exams and cleanings can
you visit an out-of-network dentist. Here’s why:
help prevent the incidence of

higher cost treatments and
In-network dentists have agreed to payment rates for various services and cannot charge you more. On
medical related issues. Dental
coverage wil provide you and
the other hand, out-of-network dentists do not have a contract with Anthem and are able to bill you for
your family affordable options
the difference between the total amount Anthem allows to be paid for a service - the maximum allowed
for overall health.
cost- and the amount they usually charge for a service. When they bill you for this difference, it is called
balance billing.”

EXAMPLE: (this is an example only. Your experience may be different, depending on your insurance plan, the services you receive and the
dentist who provides the services.)
Ted needs to get a crown and his plan allows him 50% coinsurance for either in or out-of-network services.
The cost for this service is $1,200.
Here’s the Math:
Out-Of-Network Provider
In-Network Provider

Dentist Charge:
$1,200
Dentist Charge:
$1,200
Under your dental plans, Diagnostic
Anthem’s Maximum

Anthem’s Maximum

& Preventive services such as exams,
Allowed Cost
$800
Allowed Cost
$800
Anthem Pays 50%
$400
Anthem Pays 50%
$400
cleanings, x-rays and more do not
Ted Pays 50%

Ted Pays 50%
$400
count
towards
your
annual
coinsurance
$400
coinsurance
maximum – leaving you with more
Balance Ted Owes the
$400 (difference between


Provider
charge and allowed
Provider Write Off:
$400
benefit dollars to use for other
amount)
covered dental procedures.
$400 provider balance



Ted’s Total Cost
+$400 coinsurance =$800
Ted’s Total Cost
$400 coinsurance

Minimize your out-of-pocket expense for dental care by asking your dentist for
a pre-treatment estimate before you agree to receive services for costly
procedures such as crowns, periodontal surgery and wisdom tooth extractions.
A pre-treatment estimate will not only allow you to confirm if the treatment is
covered, it will also help you to know what your cost of the treatment will be, if
you will exceed your maximum and how to best plan your payment portion. In-
network providers are responsible for obtaining a pre-treatment estimate, if
requested. If you use an out-of-network provider, you are responsible for


making sure the provider submits a written treatment plan, with the required


documentation for services to Anthem.
The PPO+ plan is a good choice

for members who live in rural

After receiving treatment from a dentist, you will receive a summary of
locations and need a larger
services that shows how much Anthem paid and what your cost share is. This
network to find an in-network
Explanation of Benefits (EOB) should always be read thoroughly and Anthem
provider.
should be contacted if there are any questions. The EOB will also indicate how
Or, if no in-network provider is
much of your deductible you have met as well as how close you are to reaching
within close proximity, the higher
your plan’s annual maximum.
coinsurance level should help
offset the member’s out-of-
To search for participating dental providers online, please visit www.anthem.com:
pocket costs on the balance

billing.

Select Find A Doctor

Select a state: (choose from drop down menu)

Select a plan/network: Dental PPO or Dental PPO Plus

Choose Select and Continue

Complete fields for provider type, specialty and location


- 24 -



VISION INSURANCE



ANTHEM BLUE CROSS
& BLUE SHIELD




The CHEIBA Trust and the CHEIBA Trust Members are pleased to offer you a comprehensive managed vision
care program. Anthem Blue View Vision offers a market-leading network with over 30,000 doctors across
the nation, as well as the Anthem Whole Health Connection. This program clinically integrates vision with
our health plan to allow the most comprehensive care for our members.



Anthem Blue View Vision Program

Your vision benefit option is separated into three components:

1. Vision Exam Only Benefit - your enrollment in any of the CHEIBA medical plans will include coverage
for a routine eye exam (once every 12 months) through the Blue View Vision Network of providers.
Your health plan rates include the premium for this benefit, and the cost may be shared between you
and your employer.
2. Vision Materials Only Benefit - if you are enrolled in a CHEIBA medical plan, you can complement
your vision coverage by electing this Voluntary eyewear materials and lens treatment option.
3. Full Service Vision Benefit - employees who are not enrolled in a CHEIBA medical plan, but would like
vision coverage can elect the Voluntary full-service (exam and materials) vision coverage.

How Anthem Blue View Vision Works:

STEP ONE:
To obtain vision care services, call your Anthem Blue View Vision provider to make an
appointment. To locate an Anthem Blue View Vision network provider, call Customer
Service at 1-866-723-0515, visit www.anthem.com/ or contact your Human
Resources/Benefit Office.

STEP TWO:
When making an appointment:
Identify yourself as an Anthem Blue View Vision member









- 25 -

VISION INSURANCE

STEP THREE:
When you arrive at your appointment, present your ID card to the office. The Anthem
Blue View Vision provider will verify eligibility and benefits via their internal system. Once
your eye exam is completed and a determination is made whether eyewear is necessary,
you can select eyeglasses or contacts at the office. Keep in mind you have the option to
purchase your materials (eyeglasses/contacts) at any in-network providers office,
including retail locations such as Sears Optical, Pearle Vision, JC Penney Optical, Target
Optical and LensCrafters. The Anthem Blue View network provider will calculate
applicable discounts and itemize any out-of-pocket expenses including copays, non-
covered lens enhancements, additional materials and/or overages. The balance must be
paid in full at the time of service.

How To Find a Provider:

With over 32,000 doctors at more than 26,000 locations nationwide, with independent
doctors, convenient retails stores and 1-800-CONTACTS - all in network - the Blue View
Vision provider network makes it easy for you and your family to take care of your vision
needs.

To search for a network provider, visit www.anthem.com and:




Select: Find a Doctor

 Select: Search by Selecting Plan or Network

 Select: State

Select a plan/network: Blue View Vision

Members can search for providers by name or location. Once you have entered the standard search
procedures, you can search for a provider offering materials by clicking on the show more options link and
selecting “materials (frames, lenses, contacts)”.





- 26 -

VISION INSURANCE

SUMMARY OF BENEFITS
Level of Coverage from an
Non-Anthem Doctor or Provider Level
Description
Anthem doctor
of Reimbursement
Blue View Vision - Exam Only
Frequency: Once every 12 months
$15 copay, then covered in full
Reimbursed up to $50
(included with your medical plan
election)



Blue View Vision - Materials Only


(Voluntary)
Eyeglass Frames
$130 allowance, then 20% off any remaining
Reimbursed up to $70
Frequency: Once every 12 months
balance
Standard Plastic Lenses
Frequency: Once every 12 months
One time materials copay of $15

(from last date of service)
Standard plastic single vision lenses
$15 copay, then covered in full
Reimbursed up to $50
Standard plastic lined bifocal lenses
$15 copay, then covered in full
Reimbursed up to $75
Standard plastic lined trifocal lenses
$15 copay, then covered in full
Reimbursed up to $100
Lenses include factory scratch coating at no additional cost. Polycarbonate and photochromic lenses are covered for dependent children under age
19 with no additional cost.
Contact Lenses*
Frequency: Once every 12 months (from


last date of service)
$130 allowance, then 15% off any remaining
Elective conventional lenses
Reimbursed up to $110
balance
Elective disposable lenses
$130 allowance
Reimbursed up to $110
Non-elective contact lenses
Covered in full
Reimbursed up to $210 allowance
Contact lens exam (Fitting &
Copayment up to $55
N/A
Evaluation)
* Contact lenses are in lieu of lenses and/or frame.
In-Network Member Cost
Eyeglass lens upgrades

(after any applicable copay)
When obtaining eyewear from a Blue
 Transitions lenses (Adults)
$75
View Vision Provider, you may choose
 Standard Polycarbonate (Adults)
$40
to upgrade your new eyeglass lenses at
 UV Coating
$15
a discounted cost. Eyeglass lens
 Progressive Lenses ¹

copayment applies.
o Standard
$65
o Premium Tier 1
$85
o Premium Tier 2
$95
o Premium Tier 3
$110
 Anti-Reflective Coating ²

o Standard
$45
o Premium Tier 1
$57
o Premium Tier 2
$68
 Other Add-ons and Services
20% off retail price
¹ Please ask your provider for his/her recommendation as well as the progressive brands by tier.
² Please ask your provider for his/her recommendation as well as the coating brands by tier.
Laser vision correction surgery


LASIK Refractive Surgery
Discount per eye
For more information please visit
www.anthem.com/specialoffers and
select vision care.
If you see an out-of-network provider, you must pay the cost in full and submit an out-of-network claim form for reimbursement up to the allowed amount.



- 27 -

VISION INSURANCE

Eyeglasses
 Lenses - Anthem Blue View Vision covers single vision, lined bifocal and lined trifocal lenses in full less the applicable copay.
 Covered Lens enhancements - Covered lens enhancements for all members include factory-scratch resistant coating.
Participants receive discounts on non-covered lens enhancements such as anti-reflective coating, tinting, UV protection and
progressive lenses.
 Frames – Frames are covered up to $130 allowance. Participants receive a 20% discount on any amount over the frame
allowance.

Contact Lenses
 Contacts are available in lieu of frames and/or lenses. If you elect to purchase contacts, the plan pays $130 towards the
purchase of the contacts. The contact benefit allowance must be used at one time. You cannot carry over any unused
balance within the year. The contact lens exam (fitting and evaluation) copay is up to $55.

Laser VisionCare Program
 Potential candidates for laser vision correction surgery can learn about this procedure by visiting
www.anthem.com/specialoffers. Anthem BVV partners with Tru Vision & Premier Lasik to offer multiple discount options for
Lasik surgery.

NOTE: These procedures are eligible expenses within the Flexible Benefit Plan Health Care Spending Account.

Additional Eyewear Benefits
 Additional sets of glasses can be obtained on the same date as an exam by the same provider at a 40% discount.

Low Vision Benefit
 The Low Vision Benefit is available to covered persons who have severe visual problems that are not correctable with regular
lenses and is subject to prior approval from Anthem’s Optometric Consultants.


Anthem Network
Non-Anthem
Provider Benefit
Provider Benefit
Supplementary Testing
Covered in Full
Up to $125.00
Complete low vision analysis and diagnosis that includes a comprehensive examination of visual functions,
including the prescription of corrective eyewear or vision aids where indicated.
Supplementary Care Aids
25% copay
Up to 75% of Cost
Subsequent low vision therapy as Visually Necessary or appropriate.
Copayment


75% of the authorized benefits payable by the Company and 25% payable by Covered Person.

The maximum low vision benefit available is $1,000 (excluding copayments) every two years.

Non-Anthem Providers
If patients choose a Non-Anthem provider, they should pay the entire bill and submit a copy of the itemized
receipt to Anthem along with a claim form that can be downloaded from www.anthem.com. If the patient
prefers, they can contact Customer Service at 1-866-723-0515 to have a form sent directly to them. Claims
must be submitted to Anthem within 180 days of the date of service. The address for submitting the claims
is located directly on the form.

Anthem Plan Limitations
This plan is designed to cover your visual needs rather than cosmetic eyewear. You will be responsible for
any additional charge on services or eyewear other than those covered by Anthem.



- 28 -

VISION INSURANCE

There is no benefit for professional services or eyewear for the following:
Orthoptics or vision training and non-prescription lenses or glasses.
Lenses and frames furnished under the plan which are lost, stolen or broken during a current 12-month
benefit period.
Medical or surgical treatment of the eyes.
Services or eyewear provided as the result of a Worker’s Compensation Law or similar legislation, or
obtained through or required by any government agency or program whether Federal, state or any
subdivision thereof.
Any service or eyewear provided by any other vision care plan or group benefit plan containing benefits
for vision care.

Exceptions to these limitations may be considered on an individual basis upon the request of the eye care
professional. Exceptions must be granted through prior authorization of Anthem and will only be
considered when the exception is deemed necessary to the patient’s visual welfare.

NOTE: This is only an overview of your vision plan choices. Review the specific vision brochures pertaining to each plan for further details
and explanations. If discrepancies are found, depend upon the certificate of coverage itself for accuracy.









- 29 -

BASIC TERM LIFE INSURANCE



Protection and security for you and your family is

important, especially in the event of a death or

accident. Therefore, the CHEIBA Trust is pleased to

offer you this Basic Term Life Insurance Plan.


ANTHEM LIFE INSURANCE COMPANY

Maximum Benefits
The amount of life insurance benefit for active Employees is calculated on your annual base salary (ask your
Human Resources/Benefits Office for specific definitions of base salary).

This plan provides the following coverage:
Under age 65 ............................................................ Two times annual base salary to a maximum of $500,000

Age 65 through 69 ...................................................... Two times annual base salary to a maximum of $50,000

Age 70 + ................................................................................................................................................... $10,000

Coverage is rounded up to the nearest $1,000.

NOTE: If an Employee takes a sabbatical and receives a lower salary during the time of the sabbatical, the
life insurance benefit will be calculated at the lower salary level.

Dependent Coverage
Under this plan, your spouse, your partner in civil union and your Eligible Dependent children have a
maximum benefit of $2,000 per person. The term Dependent means:
an Employee’s legal spouse or partner in civil union under age 70,
any married or unmarried Eligible Dependent of an Employee, either natural or legally adopted, not in
military services, over 14 days of age and until the end of the month of their 26th birthday, regardless of
tax dependent status.
Eligible Dependent children age 14 days to six months are insured for $200.
Dependent coverage excludes the following:
any person who is an Employee as defined in the policy,
any person residing outside the United States or Canada,

Beneficiary Changes
You must submit any changes in your beneficiary designation through the Human Resources/Benefits Office.

Accidental Death and Dismemberment Benefits
Should you experience an unexpected loss due to accidental death or dismemberment, Anthem Life will pay
the amount of insurance specified in the loss Schedule of Indemnities as explained in your Anthem Life
brochure.



- 30 -

BASIC TERM LIFE INSURANCE

Accelerated Benefit
If a covered person is terminally ill, he or she may be eligible for the Accelerated Benefit payment, subject to
conditions and approval. If approved, a lump sum payment of 50% of the life insurance policy or $250,000,
whichever is the lesser amount, will be issued to the insured, and further premiums will be waived.

Terminally ill is defined as being diagnosed with a life expectancy of six months or less (must be certified by
a physician). Age at time of illness and other restrictions may apply. Please contact your Human
Resources/Benefit Office if this benefit applies to you.

Retiree Coverage
When an Employee retires on or after January 1, 1997, the Retiree may elect to continue Group Term Life
Insurance under the terms of the policy by paying premiums quarterly, semiannually or annually direct to
Anthem Life.

Conversion Privileges
You, your spouse or partner in civil union may convert the current group policy to an individual policy under
certain conditions. This privilege is not available for dependent children. See your Anthem Life brochure for
details.

Portability
Upon termination of employment, you can keep your coverage at the same group rates, provided you or
your covered spouse or your Civil Union Partner are under age 70 and as long as the group continues
coverage with Anthem Life. You have the option of paying premiums quarterly, semi-annually or annually.
In order to continue coverage following termination you must apply within 31 days of your termination
date. You can obtain a form by contacting Anthem Life at 1-866-594-0516.

Insurance Premium Waiver
If you are under age 60 and become totally disabled for nine consecutive months, your insurance will
continue to age 65, without further premium payments.

Claim Notification
Written notice of the death of the person covered under the policy must be provided to Anthem Life within
two years after the date of death. If such notice is not given, Anthem Life will not be liable for any benefit
payments.

Imputed Income
Under IRS tax regulations, the imputed value of group term life insurance coverage in excess of $50,000 is
included as taxable income to an Employee. The amount of imputed income is computed based on IRS
tables and is included in taxable income each payroll period.







- 31 -

VOLUNTARY TERM LIFE & AD&D INSURANCE



Our voluntary Employee-paid term life insurance plan can be designed

to meet the needs of each individual or family. This insurance allows

you to add protection, above the Basic Term Life Insurance coverage.



ANTHEM LIFE INSURANCE COMPANY VOLUNTARY TERM LIFE
Employee Benefit
You may enroll in additional age-rated coverage in $10,000 increments to a maximum of $300,000 for yourself.
Guaranteed coverage is available to $30,000 if you are under age 60, provided you apply within your initial
eligibility period. Amounts in excess of the guaranteed amount, if you are over age 60, and if you apply after your
initial eligibility period are subject to evidence of insurability. Rates are factored in five-year bands.

Spousal and Civil Union Partner Coverage
You can enroll in additional coverage for your spouse or your Civil Union Partner (under age 70) even if you do not
enroll yourself. Spousal or Civil Union Partner coverage is also available in $10,000 increments to a maximum of
$300,000. Guaranteed coverage is available to $30,000, if the spouse or Civil Union Partner is under age 60, during
the Employee’s initial eligibility period only. Amounts in excess of the guaranteed amount, spouses or Civil Union
Partners over age 60, and if the spouse or Civil Union Partner applies after the Employee’s initial eligibility period
are subject to evidence of insurability.

Dependent Children
For a flat rate of $1.50 per month for all legally dependent children, ages six months to 26 years, you can enroll in
additional life insurance, provided you or your spouse, partner in civil union are accepted for insurance coverage.
Children are covered at $5,000 per child.

Children of Civil Union Partners
For a flat rate of $1.50 per month for all legally dependent children of your Civil Union Partner, ages six months to
26 years, you can enroll in additional life insurance, provided you or your Civil Union Partner are accepted for
insurance coverage. Children are covered at $5,000 per child.

Accelerated Benefit
If the covered person is terminally ill, he or she may choose the Accelerated Benefit, subject to conditions and
approval. If approved, a lump sum payment of 50% of the life insurance policy or $100,000, whichever is the lesser
amount, will be issued to the insured. The same conditions apply as under Basic Term Life plan. See your Human
Resources/Benefits Office if this applies to you.

Insurance Premium Waiver
If you or your spouse or Civil Union Partner are under age 60 and become totally disabled for nine consecutive
months, your insurance will continue to age 65, without further premium payments.

Suicide Exclusion
If an Employee, Employee’s spouse, or Civil Union Partner dies by suicide, while sane or insane, within one year
after the effective date of the person’s coverage, Anthem Life will refund premiums only.

Claim Notification
Written notice of the death of the covered person must be provided to Anthem Life within two years after the
date of death. If such notice is not given, Anthem Life will not be liable for any benefit payments.
NOTE: This is a general summary of your Basic & Voluntary Term Life Insurance Plans. Final interpretations and a complete listing and description of any and all benefits,
limitations and exclusions are found in, and governed by the Anthem Life Master Contracts.



- 32 -

VOLUNTARY TERM LIFE & AD&D INSURANCE

MUTUAL OF OMAHA INSURANCE COMPANY
ACCIDENTAL DEATH & DISMEMBERMENT



This voluntary Employee-paid supplemental Accidental Death and Dismemberment

Insurance is designed to offer you high limit protection against covered accidents.


Maximum Limits

You may choose to purchase coverage from $10,000 to $500,000
You may include coverage on your spouse, Civil Union Partner and dependent children
The amount of coverage purchased cannot exceed ten times your annual salary
Under the family plan coverage spouse and Civil Union Partner coverage is 50% or the employee
elected amount and dependent child coverage is 10% of the employee elected amount
If no dependent children are covered the spouse or Civil Union Partner benefit increase to 60%
If no spouse of Civil Union Partner is covered, children are covered at 20%

Benefit Payments

When covered injuries result in a loss of life within 12 months after the date of an accident, the full
benefit amounts are payable for loss of life. The full amount is also payable for the loss of two limbs,
the sight of both eyes or the loss of one limb and the sight of one eye when these losses are the result
of the same accident. One-half payment is payable for the loss of one limb, one eye, speech or hearing.
One-quarter benefit is payable for the loss of the thumb and index finger of the same hand. See the
Mutual of Omaha AD&D brochure for a complete description of loss payment schedules.

NOTE: This is only an overview of your Accidental Death & Dismemberment Plan. Please review the Mutual of Omaha AD&D brochure for further
details and explanations. If discrepancies are found, depend upon the policy itself for accuracy.



- 33 -

FLEXIBLE BENEFIT PLAN


24HOURFLEX

Flexible Spending Accounts (FSAs) allow you to set aside

pre-tax payroll deductions to pay for out-of-pocket health

care expenses such as your deductibles, copays and

coinsurance, as well as dependent care expenses.


NOTE: The information in this section does not apply to Fort Lewis College.


This Plan is offered on a voluntary basis and participation may require an administration fee.

When you choose to participate in the Flexible Benefit Plan, your monthly taxable income is reduced.
Dollars elected in the health care spending account are available to you at any time during the Plan Year.
You can claim reimbursement for eligible expenses, incurred while you are active in the plan, up to your
maximum elected amount.


Health Care Spending Account
The maximum amount of reimbursement for health care expenses is $2,550 per Employee, per calendar
year. If you wish to continue to participate in this benefit you must re-enroll in the plan each year.

Through the Health Care Spending Account, eligible out-of-pocket expenses incurred by you, your spouse
and Dependents during the Plan Year include the following items: deductibles, copayments, (non-cosmetic)
dental work, orthodontics, prescriptions, eye care, glasses, LASIK and PRK procedures, contact lenses and
more. Prescribed medications include medications that are also available over the counter as long as
participants have prescriptions from their physicians. Generally, if a medical expense is considered eligible
as a medical deduction on your federal tax return it may be eligible for pre-tax payments within your
Flexible Benefit Plan. Health-related insurance premiums cannot be paid through a Health Care Spending
Account. For a complete list of qualified medical expenses, see www.24hourflex.com.

Expenses for your Eligible Dependents may be reimbursed through this account even if they are not enrolled
in the CHEIBA Trust medical, dental or vision plans. Expenses paid by another insurance plan are not eligible
for reimbursement through the Health Care Spending Account.

HEART Act (Heroes Earnings Assistance and Relief Tax Act of 2008)
If you are a member of a reserve unit and are ordered or called to active duty, then you may be able to
request a Qualified Reservist Distribution (QRD) from your Health Flexible Spending Account (FSA). A QRD is
a taxable cash distribution of amounts from your Health FSA that is not dependent on whether you have
incurred medical expenses. You can only request this distribution if you are ordered or called to active duty
for a period in excess of 180 days or for an indefinite period. You may only request this distribution during
the period beginning on the date of the order or call and ending on the last date that reimbursements could
otherwise be made under the Plan for the Plan Year which includes the date of the order or call.


COBRA Option for the Health Care Spending Account
In the event of a COBRA qualifying event you may be eligible to continue participation in your Health Care
Spending Account through the end of your current Plan Year. This option only applies if you have a positive
balance in your account at the time of your termination or other eligible event. If you elect COBRA you must
continue to make contributions and can submit claims for reimbursement for expenses incurred while you
are on COBRA.



- 34 -

FLEXIBLE BENEFIT PLAN

Dependent Care Spending Account
You can pay up to $5,000 per family, per calendar year, for child or dependent care necessary to your
employment with pre-tax dollars. When using the Dependent Care Spending Account your expenses must
be incurred during the Plan Year. You are limited to $5,000 per year or to the income of the lesser earning
spouse (whichever is less). If your spouse is disabled or is a full-time student five months or more each year,
then the spouse’s income is considered to be $250 per month if you have one child or dependent or $500
per month if you have two or more children or dependents.

The number of children or dependents does not impact the $5,000 limit. If you are married and filing
separate tax returns, you are limited to $2,500 per spouse, per calendar year. If you wish to continue to
participate in this benefit you must re-enroll in the plan each year.

Eligible expenses must be for children under the age of 13 or for older dependents with a physical or mental
disability requiring supervision so you can work and the individual has gross income less than the exemption
amount. All care expenses must be necessary to employment. Ineligible expenses include payments for
referral services, parenting seminars, tuition expenses including kindergarten, child support payments, and
payments to a spouse or other dependent for the care of the child or dependent. Overnight camp is not an
eligible expense.

Tax Guidelines
Under current IRS regulations you must report the care provider’s name, address and Tax ID or Social
Security number on your federal tax return. This requirement is the same for both the pre-tax spending
account and the federal tax credit. You cannot pay your spouse or other dependents to care for your
children or dependents.

Eligible Expenses
The child or Dependent must live in your home on average eight hours per day. Eligible expenses include in-
home care, a child care home, child care center, summer camp, before and after-school programs and adult
day care.



NOTES:
If you have a cost change for day care during the Plan Year you may be eligible to change your election. See your
Human Resources/Benefits Office for details.
You can also use a combination of the tax credit and the pre-tax program. However, when a combination is used
you are limited to the tax credit limits for the total dollars allowed.
Expenses paid through a dependent care spending account cannot be claimed as a tax credit on your income tax
return or submitted to any other source for reimbursement.

- 35 -

FLEXIBLE BENEFIT PLAN

ENROLLMENT GUIDELINES

Enrollment
You must enroll for the Health Care Spending Account and the Dependent Care Spending Account on an
annual basis. You may change elections during the Plan Year only when a qualifying status change occurs as
described earlier in this summary and in accordance with IRS rules governing tax qualified flexible benefit
plans. Changes in a daycare provider would allow for a change in the election of the participant. They
would be allowed to stop, increase or decrease their election for this reason. Changes must be requested
within 31 days of the status change and must be approved by the Human Resources/Benefits Office.

"Use it or Lose it" - Health Care and Dependent Care Spending Accounts
You must incur eligible expenses during the Plan Year while you are an active Participant in the plan. All
claims must be received no later than April 15th of the year following the Plan Year. Dollars not claimed by
April 15th will be forfeited unless your employer offers the Roll-Over Option.
For those employers who offer a Roll-Over Option, employees participating in the Health Care Spending
Account may carryover up to $500 in unused funds into the next Plan Year. These funds will
automatically carryover to the next Plan Year if you are still in the plan as of the last day of the current
Plan Year. Please contact your Human Resources/Benefits Office for details on the rollover option.

BASIC PLAN RULES
Health Care and Dependent Care Spending Accounts
All eligible expenses must be incurred after your effective date and during the Plan Year. The incurred date
is considered the date you or your Eligible Dependent received the care, services, medicines, or purchased
supplies.

Your contributions are elected specifically to one or two accounts. The funds are maintained separately and
cannot be combined for reimbursement purposes. For example, you cannot be reimbursed from your
Health Care Spending Account for dependent care expenses.

During the enrollment process, you must carefully consider your health and child/dependent care needs and
estimate predictable expenses you will incur during the Plan Year. Important - any contributions to these
accounts that are not used for eligible expenses incurred during the Plan Year will be forfeited unless your
employer offers the Roll-Over Option. Plan carefully and set aside dollars only for those expenses you know
you will incur.


You may not change your contribution during the Plan Year except in the case of a qualifying status change
(as described earlier in this summary). Requested election changes must be submitted in writing to the
Human Resources/ Benefits Office within 31 days of the qualifying status change and all approved election
changes must be on account of or corresponding with a change in status that affects eligibility for coverage
under an employer’s plan.

Retirement Concerns
The Defined Contribution Pension Plan retirement benefits are based on the dollars contributed to the plan
over your total years of employment.

These contributions may be based on your taxable wages which are reduced by your participation in the
Flexible Benefit Plan. However, you may be able to increase your voluntary retirement plan contributions to
compensate for this reduction in contributions and reduction in future retirement benefits.

Public Employee Retirement Association (PERA) contributions are not paid on any dollars re-directed
through participation in the Flexible Benefit Plan. PERA retirement benefits are based on your highest
average salary. If you are within your final three years of employment under PERA, you may want to elect
after-tax payments for insurance premiums and decline participation in the spending accounts. Please
contact your Human Resources/Benefits Office for additional information.



- 36 -

FLEXIBLE BENEFIT PLAN


REIMBURSEMENT GUIDELINES
24HourFlex is your Flexible Benefit Plan Administrator (except for Fort Lewis College). Check with your
Human Resources/Benefits Office regarding administration fees for participation in the Flexible Benefit Plan
Spending Accounts.

For those Employers who offer the debit card, Employees participating in a Health Care Spending Account
may request a Benny Card which will be credited with their plan year elected amount. This card can be used
at most qualified health merchants; for example, pharmacies, doctor’s offices, dental offices, vision centers,
etc. When purchasing services or items with your Benny Card, you may be required to submit receipts to
show these purchases are qualified expenses. This is an IRS requirement.

Spending account reimbursement checks will be written to you personally and mailed to your home
address. You may also set up direct deposit by logging into your individual 24HourFlex account and entering
your banking information.

Health Care Spending Account Required Documentation
You must submit a copy of your provider statement or Explanation of Benefits (EOB) from the insurance
carrier along with your signed claim form when submitting for reimbursement. The following is a list of
acceptable documentation:
The itemized statement or EOB must include the date of service, service provided, family member for
whom the service was provided, amount paid and documentation that the expense was not paid by an
insurance plan
Eligible expenses cannot be paid by an insurance company or other company spending plan
Expenses must be incurred during the Plan Year, while you are an active Participant in the plan
Prescription tags or statement from pharmacy. Cash receipts are not acceptable.
Itemized receipt from store showing over-the-counter qualified expense. Receipt must show name of
item purchased, date, who from and amount.

To be reimbursed for mileage expenses, including driving Dependents to and from medical appointments,
submit your vehicle odometer readings, with the starting and ending mileage and the points of travel
(where you traveled to and from). Include the name of the family member requiring treatment, the reason
and the date of the visit. Sign and date the claim form, then submit it with the proper documentation for
reimbursement.

Expenses reimbursed in the Flexible Benefit Plan cannot be claimed as a deduction on your tax return.

Reminder: The definition of qualified medication expenses for purposes of Flexible Spending
Accounts is limited to prescribed medications and insulin. Prescribed medications include
medications that are also available over the counter as long as participants have prescriptions from
their physicians.

Dependent Care Spending Account Required Documentation
Your signed claim form must be accompanied by an itemized statement from the provider. The statement
must include the following information:
name of the Dependent
type of service rendered
name of the provider
amount charged
date(s) of service
Social Security number or Tax ID number of the provider



- 37 -

FLEXIBLE BENEFIT PLAN



For your convenience, claims can be submitted electronically at participant.24hourflex.com.

For questions:

Telephone: ................................................................................................................................... 1-800-651-4855
Email: .................................................................................................................................. info@24hourflex.com
Participant Website: .................................................................................................. participant.24hourflex.com
Address:............................................................................................................. 7100 E. Belleview Ave, Suite 300


Greenwood Village, CO, 80111


Website: ............................................................................................................................. www.24hourflex.com

NOTE: This is only an overview of your Flexible Benefit Plan. Ask your Human Resources/Benefits Office
for further details and explanations. If discrepancies are found, depend upon the plan document itself
for accuracy.

- 38 -

LONG TERM DISABILITY INSURANCE



S
When a disability affects an Employee,
TANDARD
benefit payments are available. With Long
Term Disability (LTD) Insurance, a portion
INSURANCE
of your income is protected if you are
unable to work because of a disability.



Schedule of Coverage

LTD Benefit is the lesser of the following:
66 2/3% of your pre-disability earnings to a maximum benefit of $7,000 per month; or
70% of your pre-disability earnings, reduced by deductible income (i.e., Social Security or PERA
disability).

The benefit waiting period is 90 days. The minimum monthly payment is $100. Cost-of-living adjustment
(COLA) is included.

The maximum pre-disability earnings are based on the last full day worked prior to the disability*. The
Maximum Benefit Period is determined by your age when disability begins, as follows:

Age
Maximum Benefit Period
61 or younger .............................. to age 65, or to SSNRA1, or 3 years 6 months, whichever is longest
62................................................... to SSNRA1 or 3 years 6 months, whichever is longer
63................................................... to SSNRA1 or 3 years, whichever is longer
64................................................... to SSNRA1 or 2 years 6 months, whichever is longer
65................................................... 2 years
66................................................... 1 year 9 months
67................................................... 1 year 6 months
68................................................... 1 year 3 months
69 or older ..................................... 1 year

1SSNRA = Social Security Normal Retirement Age

Exclusions
Preexisting Condition defined as treatment received during the 90-day period just before your coverage
becomes effective.

Exclusion Period .............................................................................................................................. 12 months

Limitations
Chronic Fatigue Conditions ............................................................................................................. Yes
Limitation Period ............................................................................................................................. 24 Months

Chemical and Environmental Sensitivities ...................................................................................... Yes
Limitation Period ............................................................................................................................. 24 months

* The Definition of Disability is 24-months of your own occupation and after 24 months, it is any occupation until age 65 or
SSNRA.


- 39 -

LONG TERM DISABILITY INSURANCE

Mental Disorders ............................................................................................................................. Yes
Limitation Period ............................................................................................................................. 24 months

Musculoskeletal and Connective
Tissue Disorders ......................................................................................................................... Yes
Limitation Period ............................................................................................................................. 24 months

Alcohol Use, Alcoholism or Drug Use .............................................................................................. Yes
Limitation Period: ............................................................................................................................ 24 months

Benefit Offsets
Social Security/Deductible Income
Social Security Offset: ..................................................................................................................... Full Offset

Salary Continuation Offset: ...................................................................................... Sick Pay or other salary
continuation payable to
you by your employer, but
not including vacation pay.

Survivor Benefit
In the event of your death while receiving long term disability benefits, a Survivor Benefit may be payable to
your eligible survivor. Contact the Human Resources/Benefits Office for further details.

Filing a Claim
If you have a claim, notify the Human Resources/Benefits Office immediately. You will be required to show
written proof of your disability. Claims should be filed on the appropriate forms. If you do not receive the
appropriate forms within 15 days after you request them, you may submit your claim in a letter to the
Human Resources/Benefits Office. The letter should include the date disability began and the cause and
nature of the disability.

You have 90 days after the end of the benefit waiting period to file a claim. If you cannot do so, you must
provide it to Standard as soon as reasonably possible, but not later than one year after the end of the 90-
day benefit waiting period. If a claim is filed outside these time limits, your claim may be denied. These
limits will not apply while you lack legal capacity.

For questions, call Standard Insurance Customer Service: ...................................................... 1-800-368-1135
Website .............................................................................................................................. www.standard.com



NOTE: This summary is designed to answer some common questions about LTD coverage. It is not
intended to provide a detailed description of the coverage. Ask your Human Resources/Benefits Office
for further details and explanations. The controlling provisions of coverage are in the Plan Document.
This summary and the certificate do not modify the Plan Document or coverage in any way.

- 40 -

EMPLOYEE ASSISTANCE PROGRAM

Sometimes balancing work and personal responsibilities
creates stress that is hard to handle on your own. To help
you through those times, you can receive counseling and
referrals through the Colorado State Employee Assistance
Program (C-SEAP).

What is C-SEAP?
C-SEAP is a professional assessment, referral, and short-term counseling service offered to State employees with
work-related or personal concerns, as well as a resource for supervisors and managers seeking individual
managerial consultation, work-group organizational development, assistance with conflict resolution, or help
with resolution of work-place traumatic events.

C-SEAP has confidential, cost-free counseling and coaching available for active State employees with concerns
such as:
Grief
Domestic Violence
Anger
Job Performance Concerns
Depression
Workplace Conflict
Anxiety
Substance Abuse
Stress
Couples/Family Problems
Health Concerns
Personal/Professional Growth

How do you use C-SEAP?
In order to schedule an appointment, call C-SEAP anytime Monday through Friday between the hours of 8 a.m.
and 5 p.m. When you contact C-SEAP, a staff specialist will ask you for some general information and set up an
appointment for you to meet with a counseling professional. Additional after hours resources are available on
the C-SEAP voice mail as well as on the website. You can reach C-SEAP by calling the main office 303-866-4314 or
1-800-821-8154 to schedule your initial appointment.

Where are my counseling sessions?
C-SEAP offices are located in Downtown Denver, Loveland, Sterling, Grand Junction, Colorado Springs, Pueblo,
Canon City, Alamosa and Durango.

Will anybody know I'm coming to C-SEAP for counseling?
C-SEAP does not disclose that you are coming to their office for counseling. Counseling services are strictly
confidential. The only exceptions are when you give written permission for others to be informed, or in rare
situations in which the law requires others to be informed for reasons of physical safety.



- 41 -

TRAVEL ACCIDENT INSURANCE

CHUBB
When traveling for business or pleasure, you can now feel confident that you are in safe hands if an
emergency arises. CHUBB partners with Europ Assistance, a leading global medical assistance provider, to
give you 24/7 access to medical and travel assistance services around the world.

Medical Assistance Services:
Medical Evacuation & Repatriation Services:
Medical provider search and referrals to help find hospitals
Emergency medical evacuations and medically-necessary
and doctors in a given locale
repatriation
Medial monitoring of treatment
Coordinate transportation to join a hospitalized family member
Facilitation of medical payment
Dependent children/traveling companion assistance
Coordination of medication


Benefits
The maximum benefit (Principal Sum) is $100,000 of Accidental Death and Dismemberment. If the
accidental injuries to the insured person result in death or dismemberment within 365 days of the date of
the accident, the policy will pay as follows:

Injury or Dismemberment
Policy Pays
Loss of Life
The Principal Sum
Loss of Speech & Hearing
Loss of Speech & Loss of: One Hand, One Foot, Sight of One Eye
Loss of Hearing & Loss of: One Hand, One Foot, Sight of One Eye
Loss of Both Hands, Both Feet, Sight
The Principal Sum
Loss of combination of any two: Hand, Foot, Sight of One Eye
Quadriplegia
Paraplegia
75% of Principal Sum
Hemiplegia
Loss of: Hand, Foot or Sight of One Eye (any one of each)
50% of Principal Sum
Loss of Speech or Hearing
Uniplegia
25% of Principal Sum
Loss of Thumb & Index Finger of the Same Hand

Aggregate Limit of Insurance: $1,000,000 per Accident

Access the portal:

Go to www.chubb.com/travelhelp/eb to access Europ Assistance’s portal and click on the “Sign Up Now”
link in the gray Log In box. Use your Group ID and activation Code to fill out the registration information.
Once registered, an automated email will be sent to confirm your registration. Follow the link in the email to
complete your registration.


- 42 -

LEGAL NOTICES

The Uniformed Services Employment and Reemployment Rights Act (USERRA)
USERRA provides for, among other employment rights and benefits,
continuation of medical, dental and voluntary vision coverage to a covered
Employee and covered dependents, during a period of active service or
training with any of the Uniformed Services. The Act provides that a covered
Employee may elect to continue such coverages in effect at the time the
Employee is called to active service.
The maximum period of coverage for the Employee and the covered
Employee’s dependents under such an election shall be the lesser of:
the 24-month period beginning on the date the person’s absence
begins; or
the period beginning on the date the covered Employee’s absence
begins and ending on the day after the date on which the covered
Employee fails to apply for or return to a position of employment as follows:
for service of less than 31 days, no later than the beginning of the first full regularly scheduled work
period on the first full calendar day following the completion of the period of service and the expiration
of eight hours after a period allowing for the safe transportation from the place of service to the
covered Employee’s residence or as soon as reasonably possible after such eight-hour period;
for service of more than 31 days but less than 181 days, no later than 14 days after the completion of
the period of service or as soon as reasonably possible after such period;
for service of more than 180 days, no later than 90 days after the completion of the period of service;
or
for a covered Employee who is hospitalized or convalescing from an illness or injury incurred in or
aggravated during the performance of service in the Uniformed Services, at the end of the period that
is necessary for the covered Employee to recover from such illness or injury. Such period of recovery
may not exceed two years.
A covered Employee who elects to continue health plan coverage under the Plan during a period of active
service in the Uniformed Services may be required to pay not more than 102% of the full premium under the
plan associated with such coverage for the employer’s other Employees, except that in the case of a covered
Employee who performs service in the Uniformed Services for less than 31 days, such covered Employee may
not be required to pay more than the Employee share, if any, for such coverage. Continuation coverage cannot
be discontinued merely because activated military personnel receive health coverage as active duty members
of the Uniformed Services, and their family members are eligible to receive coverage under the Department of
Defense’s managed health care program, TRICARE.
In the case of a covered Employee whose coverage under a health plan was terminated by reason of services in
the Uniformed Services, the pre-existing exclusion and waiting period may not be imposed in connection with
the reinstatement of such coverage upon reemployment under this Act. This applies to the covered Employee
who is reemployed and any dependent whose coverage is reinstated. The waiver of the pre-existing exclusion
shall not apply to illness or injury which occurred or was aggravated during performance of service in the
Uniformed Services.
“Uniformed Services” shall include full time and reserve components of the United States Army, Navy, Air
Force, Marines, Coast Guard, Army National Guard, the commissioned corps of the Public Health Service, and
any other category of persons designated by the President in time of war or emergency.
If you are a covered Employee called to a period of active service in the Uniformed Service, you should check
with the Plan Administrator for a more complete explanation of your rights and obligations under USERRA. In
the event of a conflict between this provision and USERRA, the provisions of USERRA, as interpreted by us or
your former employer, will apply.
- 43 -

LEGAL NOTICES

Premium Assistance Under Medicaid and the Children’s Health Insurance Program (CHIP)
If you or your children are eligible for Medicaid or CHIP and you’re eligible for health coverage from your employer, your state may have a premium assistance program that can
help pay for coverage, using funds from their Medicaid or CHIP programs. If you or your children aren’t eligible for Medicaid or CHIP, you won’t be eligible for these premium
assistance programs but you may be able to buy individual insurance coverage through the Health Insurance Marketplace. For more information, visit www.healthcare.gov.
If you or your dependents are already enrolled in Medicaid or CHIP and you live in a State listed below, contact your State Medicaid or CHIP office to find out if premium
assistance is available.

If you or your dependents are NOT currently enrolled in Medicaid or CHIP, and you think you or any of your dependents might be eligible for either of these programs, contact
your State Medicaid or CHIP office or dial 1-877-KIDS NOW or www.insurekidsnow.gov to find out how to apply. If you qualify, ask your state if it has a program that might
help you pay the premiums for an employer-sponsored plan.

If you or your dependents are eligible for premium assistance under Medicaid or CHIP, as well as eligible under your employer plan, your employer must allow you to enroll in
your employer plan if you aren’t already enrolled. This is called a “special enrollment” opportunity, and you must request coverage within 60 days of being determined
eligible for premium assistance. If you have questions about enrolling in your employer plan, contact the Department of Labor at www.askebsa.dol.gov or call 1-866-444-
EBSA (3272).
ALABAMA – Medicaid
FLORIDA – Medicaid
Website: http://myalhipp.com/
Website: http://flmedicaidtplrecovery.com/hipp/
Phone: 1-855-692-5447
Phone: 1-877-357-3268
ALASKA – Medicaid
GEORGIA – Medicaid
The AK Health Insurance Premium Payment Program
Website: http://dch.georgia.gov/medicaid
Website: http://myakhipp.com/
- Click on Health Insurance Premium Payment (HIPP)
Phone: 1-866-251-4861
Phone: 404-656-4507
Email: CustomerService@MyAKHIPP.com
Medicaid Eligibility: http://dhss.alaska.gov/dpa/Pages/medicaid
ARKANSAS – Medicaid
INDIANA – Medicaid
Website: http://myarhipp.com/
Healthy Indiana Plan for low-income adults 19-64
Phone: 1-855-MyARHIPP (855-692-7447)
Website: http://www.hip.in.gov
Phone: 1-877-438-4479
All other Medicaid
Website: http://www.indianamedicaid.com
Phone 1-800-403-0864
COLORADO – Medicaid
IOWA – Medicaid
Medicaid Website: http://www.colorado.gov/hcpf
Website: http://www.dhs.state.ia.us/hipp/
Medicaid Customer Contact Center: 1-800-221-3943
Phone: 1-888-346-9562
KANSAS – Medicaid
NEW HAMPSHIRE – Medicaid
Website: http://www.kdheks.gov/hcf/
Website: www.dhhs.nh.gov/oii/documents/hippapp.pdf
Phone: 1-785-296-3512
Phone: 603-271-5218
KENTUCKY – Medicaid
NEW JERSEY – Medicaid and CHIP
Website: http://chfs.ky.gov/dms/default.htm
Medicaid Website:
Phone: 1-800-635-2570
http://www.state.nj.us/humanservices/dmahs/clients/medicaid/
Medicaid Phone: 609-631-2392
CHIP Website: http://www.njfamilycare.org/index.html
CHIP Phone: 1-800-701-0710
LOUISIANA – Medicaid
NEW YORK – Medicaid
Website: http://dhh.louisiana.gov/index.cfm/subhome/1/n/331
Website: http://www.nyhealth.gov/health_care/medicaid/
Phone: 1-888-695-2447
Phone: 1-800-541-2831


- 44 -

LEGAL NOTICES

MAINE – Medicaid
NORTH CAROLINA – Medicaid
Website: http://www.maine.gov/dhhs/ofi/public-assistance/index.html
Website: http://www.ncdhhs.gov/dma
Phone: 1-800-442-6003
Phone: 919-855-4100
TTY: Maine relay 711
MASSACHUSETTS – Medicaid and CHIP
NORTH DAKOTA – Medicaid
Website: http://www.mass.gov/MassHealth
Website: http://www.nd.gov/dhs/services/medicalserv/medicaid/
Phone: 1-800-462-1120
Phone: 1-844-854-4825
MINNESOTA – Medicaid
OKLAHOMA – Medicaid and CHIP
Website: http://mn.gov/dhs/ma/
Website: http://www.insureoklahoma.org
Phone: 1-800-657-3739
Phone: 1-888-365-3742
MISSOURI – Medicaid
OREGON – Medicaid
Website: http://www.dss.mo.gov/mhd/participants/pages/hipp.htm
Website: http://healthcare.oregon.gov/Pages/index.aspx
Phone: 573-751-2005
http://www.oregonhealthcare.gov/index-es.html
Phone: 1-800-699-9075
MONTANA – Medicaid
PENNSYLVANIA – Medicaid
Website: http://dphhs.mt.gov/MontanaHealthcarePrograms/HIPP
Website: http://www.dhs.pa.gov/hipp
Phone: 1-800-694-3084
Phone: 1-800-692-7462
NEBRASKA – Medicaid
RHODE ISLAND – Medicaid
Website:
Website: http://www.eohhs.ri.gov/
http://dhhs.ne.gov/Children_Family_Services/AccessNebraska/Pages/accessnebras
ka_index.aspx
Phone: 401-462-5300
Phone: 1-855-632-7633
NEVADA – Medicaid
SOUTH CAROLINA – Medicaid
Medicaid Website: http://dwss.nv.gov/
Website: http://www.scdhhs.gov
Medicaid Phone: 1-800-992-0900
Phone: 1-888-549-0820
SOUTH DAKOTA - Medicaid
WASHINGTON – Medicaid
Website: http://dss.sd.gov Phone: 1-888-828-0059
Website: http://www.hca.wa.gov/free-or-low-cost-health- care/program-
administration/premium-payment-program Phone: 1-800-562-3022 ext. 15473
TEXAS – Medicaid
WEST VIRGINIA – Medicaid
Website: http://gethipptexas.com/ Phone: 1-800-440-0493
Website: http://www.dhhr.wv.gov/bms/Medicaid%20Expansion/Page s/default.aspx
Phone: 1-877-598-5820, HMS Third Party Liability
UTAH – Medicaid and CHIP
WISCONSIN – Medicaid and CHIP
Website:
Website: https://www.dhs.wisconsin.gov/publications/p1/p10095.pdf Phone: 1-800-
362-3002
Medicaid: http://health.utah.gov/medicaid CHIP: http://health.utah.gov/chip
Phone: 1-877-543-7669
VERMONT– Medicaid
WYOMING – Medicaid
Website: http://www.greenmountaincare.org/ Phone: 1-800-250-8427
Website: https://wyequalitycare.acs-inc.com/ Phone: 307-777-7531
VIRGINIA – Medicaid and CHIP

Medicaid Website: http://www.coverva.org/programs_premium_assistance.cfm

Medicaid Phone: 1-800-432-5924
CHIP Website: http://www.coverva.org/programs_premium_assistance.cfm CHIP
Phone: 1-855-242-8282



- 45 -

LEGAL NOTICES

WOMEN’S HEALTH AND CANCER RIGHTS ACT

All health plans offered through the CHEIBA Trust provide coverage for certain reconstructive services under
the Women’s Health and Cancer Rights Act. These services include:

reconstruction of the breast upon which a mastectomy has been performed
surgery/reconstruction of the other breast to produce a symmetrical appearance
prostheses
treatment related to physical complications during all stages of mastectomy, including lymph edemas

Refer to your certificate of coverage for specific information on coverage. The plans may apply deductibles and
copayments consistent with other coverage provided.

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 or 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 the insurance
issuer for prescribing a length of stay not in excess of 48 hours (or 96 hours).

HIPAA SPECIAL ENROLLMENT NOTICE
If you are declining enrollment 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).

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

HIPAA PRIVACY AND SECURITY

The Health Insurance Portability and Accountability Act of 1996 deals with how an employer can enforce
eligibility and enrollment for health care benefits, as well as ensuring that protected health information which
identifies you is kept private. You have the right to inspect and copy protected health information that is
maintained by and for the plan for enrollment, payment, claims and case management. If you feel that
protected health information about you is incorrect or incomplete, you may ask your benefits administrator to
amend the information. The Notice of Privacy Practices has recently been updated. For a full copy of the Notice
of Privacy Practices, describing how protected health information about you may be used and disclosed and
how you can get access to the information, contact your Human Resources department.


- 46 -

LEGAL NOTICES

CONTINUATION COVERAGE RIGHTS UNDER COBRA
You are receiving this notice because
you are covered under the CHEIBA
The right to COBRA continuation coverage was created by a federal law,
Trust (the Plan). This notice contains
Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA).
important information about your right
COBRA continuation coverage may become available to you and your
to continue your health care coverage
dependents that are covered under the Plan when you would otherwise
in the CHEIBA Trust Employee Benefit
lose your group health coverage. This notice gives only a summary of
Plan as well as other health coverage
your COBRA continuation coverage rights. For more information about
alternatives that may be available to
your rights and obligations under the Plan and under federal law, you
you through the Health Insurance
should review the Plan's Summary Plan Description or get a copy of the
Marketplace. This notice generally
Plan Document from the HealthSmart COBRA Administrator listed below.
explains COBRA continuation
COBRA continuation coverage for the Plan is administered by:
coverage, when it may become

HealthSmart
available to you and your family and

10303 E. Dry Creek Road, Suite 200
what you need to do to protect the

Englewood, CO 80112
right to receive it.

1-800-423-4445

You may have other options available to you when you lose group health coverage. For example, you may be
eligible to buy an individual plan through the Health Insurance Marketplace. By enrolling in coverage through
the Marketplace, you may qualify for lower costs on your monthly premiums and lower out-of-pocket costs.
Additionally, you may qualify for a 30-day special enrollment period for another group health plan for which
you are eligible (such as a spouse’s plan), even if that plan generally does not accept late enrollees.

What is COBRA Continuation Coverage?
COBRA continuation coverage is a continuation of Plan coverage when coverage would otherwise end because
of a life event known as a “qualifying event.” Specific qualifying events are listed later in the notice. COBRA
continuation coverage must be offered to each person who is a “qualified beneficiary”. A qualified beneficiary
is someone who will lose coverage under the Plan because of a qualifying event. Depending on the type of
qualifying event, Employees, spouses of Employees, Civil Union Partners, and dependent children may be
qualified beneficiaries. Under the Plan, qualified beneficiaries who elect COBRA continuation coverage must
pay for COBRA continuation coverage.

If you are an Employee, you will become a qualified beneficiary if you will lose your coverage under the Plan
because either one of the following qualifying events occurs:
1) Your hours of employment are reduced, or
2) Your employment ends for any reason other than gross misconduct.

If you are the spouse or Civil Union Partner of an Employee, you will become a qualified beneficiary if you will
lose your coverage under the Plan because any one of the following qualifying events occurs:
1) The Employee dies;
2) The Employee’s hours of employment are reduced;
3) The Employee’s employment ends for any reason other than gross misconduct;
4) The Employee becomes enrolled in Medicare (Part A, Part B, or both);
5) You become divorced or legally separated from your spouse; or

6) The civil union is dissolved.

Your dependent children and the dependent children of a Civil Union Partner will become qualified
beneficiaries if they will lose coverage under the Plan because any one of the following qualifying events
occurs:
1) The parent/Employee dies;
2) The parent/Employee's hours of employment are reduced;
3) The parent/Employee's employment ends for any reason other than his or her gross misconduct;
4) The parent/Employee becomes enrolled in Medicare (Part A, Part B, or both);
5) The parents become divorced or legally separated;
6) The child stops being eligible for coverage under the plan as a “dependent child”; or
7) The civil union is dissolved.


- 47 -

LEGAL NOTICES

When is COBRA Coverage Available?
The Plan will offer COBRA continuation to qualified beneficiaries only after the Plan Administrator has been
notified in a timely manner that a qualifying event has occurred. When the qualifying event is the end of
employment or reduction of hours of employment, death of the Employee, or enrollment of the Employee in
Medicare (Part A, Part B, or both), the employer must notify the Plan Administrator of the qualifying event.

Employees Must Give Notice of Some Qualifying Events
For the other qualifying events (divorce or legal separation of the Employee and spouse or a dependent child's
losing eligibility for coverage as a dependent child), you must notify the Plan Administrator. The Plan requires
you to notify the Plan Administrator in writing within 60 days after the later of the qualifying event or the loss
of coverage.

IF YOU, YOUR SPOUSE, CIVIL UNION PARTNER, OR DEPENDENT CHILDREN DO NOT ELECT CONTINUATION
COVERAGE WITHIN THIS 60-DAY ELECTION PERIOD, YOU WILL LOSE YOUR RIGHT TO ELECT CONTINUATION
COVERAGE.

How is COBRA Coverage Provided?
Once the Plan Administrator receives notice that a qualifying event has occurred, COBRA continuation coverage
will be offered to each of the qualified beneficiaries. Each qualified beneficiary will have an independent right
to elect COBRA continuation coverage. Covered Employees may elect COBRA continuation coverage on behalf
of their spouses and Civil Union Partners, and parents may elect COBRA continuation coverage on behalf of
their children. For each qualified beneficiary who elects COBRA continuation coverage, COBRA continuation
coverage will begin either (1) on the date of the qualifying event or (2) on the date that Plan coverage would
otherwise have been lost, depending on the nature of the Plan.

How long will COBRA Coverage Last?
COBRA continuation coverage is a temporary continuation of coverage. When the qualifying event is the death
of the Employee, your divorce or legal separation, or a dependent child losing eligibility as a dependent child,
COBRA continuation coverage lasts for up to 36 months.

When the qualifying event is the end of employment or reduction of the Employee's hours of employment, and
the Employee became entitled to Medicare benefits less than 18 months before the qualifying event, COBRA
continuation coverage for qualified beneficiaries other than the Employee lasts until 36 months after the date
of Medicare entitlement. For example, if a covered Employee becomes entitled to Medicare eight months
before the date on which his employment terminates, COBRA continuation coverage for his spouse and
children can last up to 36 months after the date of Medicare entitlement, which is equal to 28 months after the
date of the qualifying event (36 months minus eight months).

Otherwise, when the qualifying event is the end of employment or reduction of the Employee's hours of
employment, COBRA continuation coverage generally lasts for only up to a total of 18 months. There are two
ways in which this 18-month period of COBRA continuation coverage can be extended.

Disability Extension of 18-month Period of Continuation Coverage
If you or anyone in your family covered under the Plan is determined by the Social Security Administration
or PERA to be disabled and you notify the Plan Administrator in a timely fashion, you and your entire family
may be entitled to receive up to an additional 11 months of COBRA continuation coverage, for a total
maximum of 29 months. The disability would have to have started at some time before the 60th day of
COBRA continuation coverage and must last at least until the end of the 18-month period of continuation
coverage. This notice should be sent to the HealthSmart COBRA Administrator.


- 48 -

LEGAL NOTICES


Second Qualifying Event Extension of 18-month Period of Continuation Coverage
If your family experiences another qualifying event while receiving COBRA continuation coverage, the
spouse and dependent children in your family can get additional months of COBRA continuation coverage,
up to a maximum of 36 months. This extension is available to the spouse and dependent children if the
former Employee dies, or gets divorced or legally separated. The extension is also available to a dependent
child when that child stops being eligible under the Plan as a dependent child, but only if the event would
have caused the spouse or dependent child to lose coverage under the Plan had the first qualifying event
not occurred. In all of these cases, you must make sure that the Plan Administrator is notified of the
second qualifying event within 60 days of the second qualifying event. This notice must be sent to the
HealthSmart COBRA Administrator.
Continuation coverage will be terminated before the end of the maximum period if:
any required premium is not paid in full on time,
a qualified beneficiary first becomes covered, after electing continuation coverage, under another
group health plan,
a qualified beneficiary first becomes entitled to Medicare benefits (under Part A, Part B, or both) after
electing continuation coverage, or
the employer ceases to provide any group health plan for its employees.

Continuation coverage may also be terminated for any reason the Plan would terminate coverage of a
participant or beneficiary not receiving continuation coverage (such as fraud).
Domestic Partners
All eligibility and coverage for domestic partners and the children of domestic partners was closed effective
January 1, 2016, provided however that coverage for any domestic partner and the children of the domestic
partnership is effective through December 31, 2016, if such coverage was in effect on December 31, 2015.
After December 31, 2016, all coverage for domestic partners and the children of domestic partners is
terminated.

The CHEIBA Trust and the CHEIBA Trust Members approved 18 months of COBRA coverage to domestic
partners and the children of domestic partners whose coverage is in effect on December 31, 2016.

Domestic partners and children of domestic partners who are covered under a CHEIBA medical, dental or
vision plan will receive a Cobra Election Notice with the information that is necessary to maintain coverage
for up to 18 months.


If You Have Questions
If you have questions about your COBRA continuation coverage, you should contact the HealthSmart COBRA
Administrator at 1-800-423-4445 or send an email to askcobra@healthsmart.com.

COBRA Premium Payment Guidelines
Generally, each qualified beneficiary may be required to pay the entire cost of continuation coverage. The
amount a qualified beneficiary may be required to pay may not exceed 102% of the cost to the group health
plan (including both employer and employee contributions) for coverage of a similarly situated plan participant
or beneficiary who is not receiving continuation coverage. The required payment guidelines will be provided at
the time of COBRA enrollment.
If you elect continuation coverage, you do not have to send any payment with the Election Form. However,
you must make your first payment for continuation coverage not later than 45 days after the date of your
election. (This is the date the Election Notice is postmarked, if mailed) If you do not make your first payment
for continuation coverage in full no later than 45 days after the date of your election, you will lose all
continuation coverage rights under the Plan. You are responsible for making sure that the amount of your first
payment is correct. You may contact the HealthSmart COBRA Administrator to confirm the correct amount of
your first payment.
After you make your first payment for continuation coverage, you will be required to make periodic payments
for each subsequent coverage period. The periodic payments may be made on a monthly basis. After the first
payment, the periodic payments are due on the first of the month.


- 49 -

LEGAL NOTICES

Although periodic payments are due on the dates shown above, you will be given a grace period of 30 days
after the first day of the coverage period to make each periodic payment. Your continuation coverage will be
provided for each coverage period as long as payment for that coverage period is made before the end of the
grace period for that payment. If you fail to make a periodic payment before the end of the grace period for
that coverage period, you will lose all rights to continuation coverage under the Plan.
The monthly premium for continuation of the Health Care Flexible Spending Account is based on the annual
amount you choose to contribute to the account and the number of months remaining under COBRA coverage
during the period for which the employee made the election. The Plan may charge additional administrative
fees for continued participation.

Keep Your Plan Administrator Informed of Address Changes
In order to protect your family's rights, you should keep the Plan Administrator informed of any changes in
the addresses of family members. You should also keep a copy, for your records, of any notices you send to
the Plan Administrator.

Important HIPAA Information:
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) includes some provisions that may
affect decisions you make about your participation in the Group Health Plan under the Consolidated Omnibus
Budget Reconciliation Act of 1985 (COBRA). These provisions are as follows:
1) Under HIPAA, if a qualified beneficiary is determined by the Social Security Administration to be disabled
under the Social Security Act at any time during the first 60 days of COBRA coverage, the 11-month
extension is available to all individuals who are qualified beneficiaries due to the termination or reduction
in hours of employment. The disabled individual can be a covered Employee or any other qualified
beneficiary.

However, to be eligible for the 11-month extension, affected individuals must still comply with the
notification requirements.

2) A child that is born to or placed for adoption with the covered Employee during a period of COBRA
coverage will be eligible to become a qualified beneficiary. In accordance with the terms of the employer's
group health plan(s) and the requirements of Federal law, these qualified beneficiaries can be added to
COBRA coverage upon proper notification to the Plan Administrator of the birth or adoption.

If you have any questions about COBRA, or if you have changed marital status, or you or your spouse have
changed addresses, please contact the HealthSmart COBRA Administrator or send an email to
askcobra@healthsmart.com.

- 50 -

LEGAL NOTICES

IMPORTANT NOTICE FROM THE CHEIBA TRUST
ABOUT YOUR PRESCRIPTION DRUG COVERAGE AND
MEDICARE (CREDITABLE COVERAGE NOTICE)

Please read this notice carefully and keep it where you can find it. This notice has information about your
current prescription drug coverage through the CHEIBA Trust and prescription drug coverage available for
people with Medicare. It also explains the options you have under Medicare prescription drug coverage and
can help you decide whether or not you want to join a Medicare drug plan. If you are considering joining,
you should compare your current coverage, including which drugs are covered at what cost, with the
coverage and costs of the plans offering Medicare prescription drug coverage in your area. At the end of this
notice is information about where you can get help to make decisions about your prescription drug coverage.
Please share this information with any other family member who is covered under the plan and who may be
eligible for Medicare Part D.

1. Medicare prescription drug coverage became available in 2006 to everyone with Medicare through
Medicare prescription drug plans and Medicare Advantage Plans that offer prescription drug
coverage. All Medicare prescription drug plans provide at least a standard level of coverage set by
Medicare. Some plans may also offer more coverage for a higher monthly premium.
2. The CHEIBA Trust has determined that the prescription drug coverage offered through the CHEIBA Trust
for the HMO/POS, PRIME Blue Priority PPO, Blue Priority HMO, Lumenos 2500 and Custom Plus plans is,
on average for all plan participants, expected to pay out as much as the standard Medicare prescription
drug coverage pays and is, therefore, considered Creditable Coverage. Because your existing coverage is
Creditable Coverage you can keep this coverage and not pay a higher premium (a penalty) if you later
decide to enroll in a Medicare prescription drug plan.
Individuals can enroll in a Medicare prescription drug plan when they first become eligible for Medicare and
each year from October 15th through December 7th. However, if you lose your current creditable prescription
drug coverage, through no fault of your own, you will be eligible for your two-month Special Enrollment Period
(SEP) to join a Medicare drug plan.

If you decide to join a Medicare drug plan, your CHEIBA Trust coverage will be affected.

If you do decide to join a Medicare drug plan and drop your CHEIBA Trust prescription drug coverage, be
aware that you and your dependents may not be able to get this coverage back.

You should also know that if you drop or lose your coverage with the CHEIBA Trust and don’t join a Medicare
drug plan within 63 continuous days after your current coverage ends, you may pay a higher premium (a
penalty) to join a Medicare drug plan later.

If you go 63 continuous days or longer without creditable prescription drug coverage, your monthly premium
may go up at least 1% of the Medicare base beneficiary premium per month for every month that you did
not have that coverage. For example, if you go nineteen months without creditable coverage, your premium
may consistently be at least 19% higher than the Medicare base beneficiary premium. You may have to pay
this higher premium (a penalty) as long as you have Medicare prescription drug coverage. In addition, you
may have to wait until the following October to join.

For more information about this notice or your current prescription drug coverage, please reference the
Multi-Option Plan Summary included in the back pocket of the Benefit Booklet or contact your Human
Resources/Benefits Office for further information. NOTE: You will receive this notice annually and at other
times in the future such as before the next period you can join a Medicare drug plan, and if this coverage
through the CHEIBA Trust changes. You also may request a copy of this notice at any time.
- 51 -

LEGAL NOTICES

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

More detailed information about Medicare plans that offer prescription drug coverage is in the “Medicare
& You” handbook. You’ll get a copy of the handbook in the mail every year from Medicare. You may also
be contacted directly by Medicare prescription drug plans. For more information about Medicare
prescription drug coverage:
Visit www.medicare.gov
Call your State Health Insurance Assistance Program (see the inside back cover of your copy of the "Medicare & You"
handbook for their telephone number) for personalized help,
Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048.

For people with limited income and resources, extra help paying for Medicare prescription drug coverage is
available. Information about this extra help is available from the Social Security Administration (SSA) on the
web at www.socialsecurity.gov, or you can call them at 1-800-772-1213 (TTY 1-800-325-0778).

REMEMBER: Keep this Creditable Coverage notice. If you decide to join one of the Medicare drug plans, you
may be required to provide a copy of this notice when you join to show whether or not you have maintained
creditable coverage and, therefore, whether or not you are required to pay a higher premium (a penalty).

Date:
9/19/2016
Date:
9/19/2016
Name of Entity/Sender:
Adams State University
Name of Entity/Sender:
Fort Lewis College
Contact--Position/Office:
Human Resources/ Benefits Office
Contact--Position/Office:
Human Resources/ Benefits Office
Address:
208 Edgemont Blvd.
Address:
1000 Rim Drive
Alamosa, CO 81101
Durango, CO 81301-3999
Phone Number:
719-587-7990
Phone Number:
970-247-7428
Date:
9/19/2016
Date:
9/19/2016
Name of Entity/Sender:
Auraria Higher Education
Name of Entity/Sender:
Metropolitan State University of
Center
Denver
Contact--Position/Office:
Human Resources/ Benefits Office
Contact--Position/Office:
Human Resources/ Benefits Office
Address:
Campus Box C, PO Box 173361
Address:
Campus Box 47, PO Box 173362
1201-5th Street, #370
Student Success Building
Denver, CO 80217-3361
890 Auraria Parkway, Suite 310
Denver, CO 80217-3362
Phone Number:
303-556-3384
Phone Number:
303-556-3120
Date:
9/19/2016
Date:
9/19/2016
Name of Entity/Sender:
Colorado School of Mines
Name of Entity/Sender:
University of Northern Colorado
Contact--Position/Office:
Human Resources/ Benefits Office
Contact--Position/Office:
Human Resources/ Benefits Office
Address:
1500 Illinois Street
Address:
Carter Hall, Rm. 2002
Golden, CO 80401
Campus Box 54
Greeley, CO 80639
Phone Number:
303-273-3052
Phone Number:
970-351-2718
Date:
9/19/2016
Date:
9/19/2016
Name of Entity/Sender:
Colorado State University -
Name of Entity/Sender:
Western State Colorado
Pueblo
University
Contact--Position/Office:
Human Resources/ Benefits Office
Contact--Position/Office:
Human Resources/ Benefits Office
Address:
2200 Bonforte Boulevard
Address:
600 N. Adams Street
Pueblo, CO 81001
Taylor Hall, Room 321
Gunnison, CO 81231
Phone Number:
719-549-2441
Phone Number:
970-943-3140
Date:
9/19/2016


Name of Entity/Sender:
Colorado State University –


Global Campus
Contact--Position/Office:
Human Resources/ Benefits Office


Address:
7800 East Orchard Road, #200


Greenwood Village, CO 80111
Phone Number:
720-279-0168




- 52 -

GLOSSARY OF TERMS


Balance Billing – Out-of-network reimbursements are based on a
maximum allowable fee schedule. If the provider’s charge exceeds the
maximum allowable fee schedule amount, you pay the excess amount as out-
of-pocket expenses.
Beneficiary – means the person or entity designated by the participant to
receive any death benefits payable under the terms of any benefit plan.

CHEIBA TrustThe Colorado Higher Education Insurance Benefits Alliance Trust (CHEIBA Trust) is a
benefit purchasing consortium and trust made up of Adams State University, Auraria Higher Education
Center, Colorado School of Mines, Colorado State University - Pueblo, and Colorado State University - Global
Campus, Fort Lewis College, Metropolitan State University of Denver, University of Northern Colorado and
Western State Colorado University.
CHEIBA Trust CommitteeThe Trust Committee was formed pursuant to Article III of the Colorado
Higher Education Insurance Benefits Alliance Trust (CHEIBA Trust) Agreement. Each participating college
shall designate one of its Employees to serve as a Trustee and member of the Trust Committee.
Copaymenta cost-sharing arrangement in which a covered person pays a specified charge for a
specified service, such as $15 for an office visit. The covered person is usually responsible for the charge at
the time the health care is rendered. Typical copayments are fixed or variable flat amounts for physician
office visits, prescriptions or hospital services. Some copayments are referred to as coinsurance, with the
distinguishing characteristics that copayments are flat or variable dollar amounts and coinsurance is a
defined percentage of the charges rendered.
Coinsurancethe portion of covered health care costs for which the covered person has a financial
responsibility, usually according to a fixed percentage. Often coinsurance applies after first meeting a
deductible requirement.
Consolidated Omnibus Budget Reconciliation Act (COBRA) – is a federal law that,
among other things, requires employers to offer continued health insurance coverage to certain Employees
and their beneficiaries whose health insurance coverage has terminated.
Creditable Coverage – under the simplified method, a prescription drug plan is deemed to be
creditable if it:
1) Provides coverage for brand and generic prescriptions;
2) Provides reasonable access to retail providers and, optionally, for mail order coverage;
3) It is designed to pay on average at least 60% of participants’ prescription drug expenses; and
4) Satisfies at least one of the following:


For plans that are not integrated (a plan that provides Rx benefits that are separate from the medical
plan, i.e., does not share a common deductible):
a) The prescription drug coverage has no annual benefit maximum or a maximum benefit payable by
the plan of at least $25,000, or
b) The prescription drug coverage has an actuarial expectation that the amount payable by the plan
will be at least $2,000 per Medicare eligible individual in 2008.

For integrated plans (a plan where medical and Rx expenses are subject to the same deductible):
a) For entities that have integrated health coverage, the integrated health plan has no more than a
$250 deductible per year, has no annual benefit maximum or has a maximum annual benefit
payable by the plan of at least $25,000 and has no less than a $1,000,000 lifetime combined benefit
maximum.
Deductible - the amount of eligible expenses a covered person must pay each year from his/her own
pocket before the plan will make payment for eligible benefits.
Drug Formulary – a listing of prescription medications which are preferred for use by the health plan
and which will be dispensed through participating pharmacies to covered persons. This list is subject to
periodic review and modification by the health plan. A plan that has adopted an “open or voluntary”
formulary allows coverage for both formulary and non-formulary medications. A plan that has adopted a
“closed, select or mandatory” formulary limits coverage to those drugs in the formulary.
- 53 -

GLOSSARY OF TERMS

Federal Family and Medical Leave Act (FMLA) – This Act requires an employer which
employs 50 or more employees (within a 75-mile radius) to allow an employee who has been employed for
at least 12 months by the employer and for at least 1,250 hours of service with such employer during the
previous 12-month period, to take a total of 12 weeks of leave during any 12-month period, as defined by
the employer for:
1) the birth of a child;
2) the placement of a child with the employee for adoption or foster care;
3) the care for a spouse, child or parent of the employee if the individual has a serious health condition; or
4) a serious health condition which prevents the employee from performing the function of his/her regular
position.
Flexible Spending Accounts – tax-free accounts which allow Employees to set aside pre-tax dollars
from their gross wages to later be reimbursed tax free for eligible expenses incurred during the Plan Year.
Unclaimed dollars are forfeited to the employer. Accounts include a Health Care Spending Account for out-
of-pocket health care expenses for the family and a Dependent Care Spending Account for dependent care
expenses necessary to employment. There is also a pre-tax insurance payments process which allows
Employees to use their pre-tax dollars to pay their share of all the CHEIBA Trust sponsored health-related
insurance premiums.
Generic Druga chemically equivalent copy designed from a brand name drug whose patent has
expired. A generic is typically less expensive and sold under a common or “generic” name for that drug
(e.g., the brand name for one tranquilizer is Valium, but it is also under the generic name diazepam). Also
called generic equivalent.
Health Maintenance Organization (HMO) - an entity that provides, offers or arranges for
coverage of designated health services needed by Plan members for a fixed, prepaid premium. There are
four basic models of HMOs: group model, individual practice association, network model and staff model.
Under the federal HMO Act, an entity must have three characteristics to call itself an HMO: an organized
system for providing health care or otherwise assuring health care delivery in a geographic area, an agreed
upon set of basic and supplemental health maintenance and treatment services and a voluntary enrolled
group of people.
Health Savings Account – An HSA is a tax-favored savings account that, when paired with a
qualified High Deductible Health Plan (HDHP), allows you to pay for qualified medical expenses, or leave
funds invested in the account for future medical expenses tax-free. An HSA account is a personal, portable
account and remains in your control regardless of your employment. A Health Savings Account can be
established through any qualifying financial institution. Please contact your financial advisor or banking
institution for more information.
High Deductible Health Plan – A High Deductible Health Plan is a health insurance plan that has a
high minimum deductible which does not cover the initial costs or all of the costs of medical expenses. The
deductible must be met by the insurance holder before the insurance coverage kicks in.
HIPAA - HIPAA is the “Health Insurance Portability and Accountability Act of 1996”. HIPAA is federal
legislation designed to improve the portability of health coverage, to make system administrative
simplification changes and to protect privacy rights.
In-Network Services – health care delivered by a participating provider who has contracted with the
health plan to deliver medical services to covered persons.
Medicare Part “D” – prescription drug benefit provisions (Medicare Part D) of the Medicare
Prescription Drug, Improvement, and Modernization Act of 2003 (MMA). Part D prescription drug program
is available to Medicare beneficiaries.
Out-of-Network Services – health care delivered by a non-participating provider who has not
contracted with the health plan.
Out-of-Pocket Costs / Expenses – the portion of payments for health services required to be paid
by the enrollee, including copayments, coinsurance and deductibles.
Out-of-Pocket Limit – the total payments toward eligible expenses that a covered person funds for
himself/herself and/or Dependents: i.e., deductibles, copayments, and coinsurance, as defined per the
contract. Once this limit is reached, benefits will increase to 100% for health services received during the
rest of that calendar year. Some out-of-pocket costs (e.g., mental health, penalties for non-pre-certification,
etc.) are not eligible for out-of-pocket limits.
Plan Year – the CHEIBA Trust Plan year is a calendar year.


- 54 -

GLOSSARY OF TERMS

Point-of-Service (POS) Plan – a health plan allowing the covered person to choose to receive a
service from a participating or non-participating provider, with different benefit levels associated with the
use of participating providers. Point-of-Service can be provided in several ways:
an HMO may allow members to obtain limited services from non-participating providers;
an HMO may provide non-participating benefits through a supplemental major medical policy;
a PPO may be used to provide both participating and non-participating levels of coverage and access; or
various combinations of the previous options may be used.
Preferred Provider Organization (PPO) – is a network of physicians and hospitals who have
agreed to a set fee schedule, thereby saving money for the covered person.
Primary Care Physician (PCP) – a physician the majority of whose practice is devoted to internal
medicine, family/general practice and pediatrics. A primary care physician is accountable for the total
health services of enrollees, arranges referrals and supervises other care, such as specialist services and
hospitalization.
Trust or Trust Agreement – refers to the CHEIBA Trust, as defined above.






































- 55 -