OPEN ENROLLMENT GUIDE
For FY2017 Employee Benefits
Monday, May 2, 2016 – Friday, June 3, 2016
Messiah College offers eligible employees a comprehensive and valuable benefits program. Open Enrollment is the
period in which eligible employees have the opportunity to enroll or change their options for health and welfare benefits.
The changes you make during Open Enrollment will be effective July 1, 2016.
There are a two changes to your benefits for the 2016 plan year.
Capital Blue Cross will remain our health insurance provider and we will continue to offer three health plans. However,
there are some changes to the plan structures (changes highlighted in yellow below).
PPO 1500
In Network
Deductible
Individual
Family
Out of Pocket Max
Individual
Family
Deductible
Individual
Family
Out of Pocket Max
Individual
Family
Deductible
Individual
Family
Out of Pocket Max
Individual
Family
Out of Network
$1,500
$3,000
$3,000
$6,000
$3,000
$6,000
HSA
In Network
$6,000
$12,000
Out of Network
$2,000
$4,000
$4,000
$8,000
$3,500
$7,000
CARE CONNECT
PCP Directed
Self-Directed Care
Care
$500
$1,000
$1,000
$2,000
$2,000
$4,000
$7,000
$14,000
Out-of-Network
$3,000
$6,000
$6,350
$12,700

Health Savings Account: The College will continue to contribute to the plan at the levels listed below for
individuals on the High Deductible Health Plan. However, the College contribution will no longer be
deposited quarterly. The full annual contribution will be contributed in mid-July. Employee
contributions can be made each pay or in one-time contributions.
o Individual Coverage: $900 annually
o Family Coverage:
$1,800 annually

Flexible Spending Accounts: AmeriFlex will no longer be our plan administrator. Discovery Benefits
will administer the plan.
The elections you make during open enrollment will become effective July 1, 2016 and remain in effect for the entire year
(July 1, 2016 through June 30, 2017) unless you have a qualified life event.
Qualified life events include:
• Marriage
• Divorce
• Legal separation
• Status change
• Birth or adoption of a child
• Change in child’s dependent status
• Death of a spouse, child or other qualifying dependent
• Commencement or termination of adoption proceedings
• Change in spouse’s benefits or employment status.
Open Enrollment forms are included in this packet. They will also be available at:
http://www.messiah.edu/info/20590/benefits/975/benefits_forms
You must complete the 2016-2017 Open Enrollment form for any benefit you are adding, deleting or changing. In
conjunction with that, you must complete the appropriate enrollment/change form. Most of the open enrollment forms are
included in this document.
ALL FORMS ARE DUE TO SU DEITCH NO LATER THAN
FRIDAY, JUNE 3, 2016
Please contact Su Deitch at x7085 or [email protected] if you have questions.
2016-2017 OPEN ENROLLMENT BENEFIT ELECTION FORM
YOUR PERSONAL INFORMATION
Name
Messiah I.D.
Last
First
M.I.
Address
Soc. Sec. No. ________-_____-_________
Street
City
State
`
Birth Date _______/______/_______
Zip Code
1. Medical Plan - Capital Blue Cross
4. Long Term Care - Genworth
Choose plan
Choose coverage level
PPO Plan
To enroll, go to http://enroll.jhcorpchoice.com (username: messiah; password: mybenefit)
Single (01)
5. Aflac Benefits
Complete Capital Blue Cross form
Employee/Child(ren) (02)
Please contact Christopher Lupp at 717.695.9377, ext 226 if you are interested in Aflac benefits.
Care Connect Plan
Employee/Spouse (03)
Complete Capital Blue Cross form
6. Met Life Voluntary Life Insurance
High Deductible/Health Savings Account Plan
Family (04)
I wish to enroll
Complete Capital Blue Cross form
Family (employee/spouse both
employed by Messiah) (05)
Waive Medical Coverage
(complete MetLife enrollment form and a Statement of Health for each person to
be covered under the plan)
I wish to drop coverage
Complete Waiver Form
2. Dental Plan - The Guardian DentalGuard Preferred
Type of Coverage
Single (01)
No
Coverage
Employee/Child(ren) (02)
Coverage
Complete Guardian
Dental Only Enrollment Form
6. Flexible Spending Accounts for ACO and PPO Plans and Waiver Participants
Health Care Account
Dependent Care Account
I wish to participate.
I wish to participate.
Complete the Flex Plan enrollment form.
Complete the Flex Plan enrollment form.
Employee/Spouse (03)
Maximum contribution $2550.00
Maximum contribution $5000.00
Family (04)
7. Health Savings Account for High Deductible Health Plan Participants Only
Family (employee/spouse both
employed by Messiah) (05)
I wish to contribute.
Complete the HSA Contribution form.
8. Enhanced Tuition Reduction Benefit
3. Vision Plan - Capital BlueCross
Type of Coverage
I wish to participate for the 2016-2017 academic year.
Single (01)
No
Coverage
Coverage
Complete the Capital
Two Party (02)
In order to receive the Enhanced Tuition Reduction Benefit for the 2016-17 academic year,
you must elect the benefit during Open Enrollment.
Blue Cross form
Family (03)
YOUR AUTHORIZATION
I am electing benefits identified on this form for Plan Year 2016-2017. By my signature below, I authorize my employer to make the indicated changes and deduct premiums from my paycheck.
I understand that I cannot change or adjust my elections or deductions during the Plan Year unless a change occurs (e.g. life event, marriage, birth, divorce), or unless
I experience some other qualifying event.
Employee Signature
Date
Manager of Benefits Signature
Date Entered in System
Open Enrollment Form MC 2017
OPEN ENROLLMENT INSTRUCTIONS
For FY2017 Employee Benefits
MEDICAL/RX PLANS
IF YOU ARE NOT CHANGING YOUR MEDICAL COVERAGE, YOUR CURRENT COVERAGE WILL CARRY
OVER INTO THE NEW BENEFIT YEAR.
If you would like to newly elect medical coverage, please request a Capital Blue Cross Enrollment
Packet from Su Deitch in Human Resources and complete:
 2016-2017 Open Enrollment form, section 1
 Capital Blue Cross Application to Enroll or Change Enrollment Form (available at
http://www.messiah.edu/info/20590/benefits/975/benefits_forms)
o Complete section 1 using your Social Security number as the Subscriber Identification
o Complete section 2 for each family member you choose to cover
o Complete section 3 as follows:
 Check the PPO and Drug boxes for each person you are covering on the plan
o Complete section 4 if you are electing the Care Connect Plan.
o Complete sections 5, 6, 7, 8 or 9, if applicable
o Write the name of the plan you are selecting in large letters across the top of the form (PPO,
Care Connect or HSA)
o Sign in Section 10.
If you are dropping medical coverage, please complete:
 2016-2017 Open Enrollment form, section 1
 Waiver of Health Insurance
The Waiver Bonus DOES NOT carry over from year to year. If you wish to continue to waive
medical coverage, please complete:


2016-2017 Open Enrollment form, section 1
Waiver of Health Insurance
WAIVER OF HEALTH INSURANCE
In consideration of Messiah College’s promise to pay a waiver bonus in the amount of
$1,000.00 (paid on a pro-rated basis), I agree to waive the health insurance coverage
provided by the College. I understand that my waiving of coverage is in effect for the
entire plan year beginning July 1, 2016 and ending on June 30, 2017 unless I
experience a qualified family status change.* The waiver is not available for
employees who have a benefits-eligible spouse working at Messiah College. I hereby
state that I will be covered by another health insurance plan during the entire period of
the waiver as indicated below:
Other Health Insurance Information
Name of Policy Holder
Policy Holder’s Employer
Name of Health Care Plan/Insurance
Employee Signature
Date
Please print name
* Family status changes are governed by the Internal Revenue Code and include
marriage, divorce, birth or adoption of a child, death of spouse or child, spouse
beginning or terminating employment and you or a spouse having a significant
change in work hours that affects your benefits coverage.
Benefit Highlights
CareConnect Select Plan
www.capbluecross.com
Messiah College
THIS IS NOT A CONTRACT. This information highlights some of the benefits available through this program and is NOT intended to be a complete list or description of available
services. Benefits are subject to the exclusions and limitations contained in your Certificate of Coverage (COC). Refer to your COC for benefit details.
Amounts Members Ar e Responsible For:
SUMMARY OF COST-SHARING
Deductible (per benefit period)
PCP-Directed Care
Self-Directed Care
Out-of-Network Care
$500 per member
$1,000 per family
$1,000 per member
$2,000 per family
$3,000 per member
$6,000 per family
 Office Visits (Family Practitioner, General Practitioner, Internist,
Pediatrician)
$20 copayment per visit
50% coinsurance
50% coinsurance
 Specialist Office Visit
$40 copayment per visit
50% coinsurance
50% coinsurance
Deductible may be waived for certain services related to chronic
condition management.
Copayments
 Emergency Room
$200 copayment per visit, waived if admitted
 Urgent Care
$100 copayment per visit
 Inpatient (Per Admission)
Not Applicable
50% coinsurance
50% coinsurance
 Outpatient Surgery Copayment (facility)
Not Applicable
50% coinsurance
50% coinsurance
 High Tech Imaging
Not Applicable
50% coinsurance
50% coinsurance
Not Applicable
50% coinsurance
50% coinsurance
Coinsurance
Out-of-Pocket Maximum (includes Deductible, Copayments and
Coinsurance for Medical (including ER) and Prescription Drug).
When the out-of-pocket maximum is reached, benefits are paid at 100%
of the allowable amount until the benefit period ends.
SUMMARY OF BENEFITS
Limits and
Maximums
$2,000 per member
$4,000 per family
$6,350 per member
$12,700 per family
Amounts Members Are Responsible For:
PCP-Directed Care
Self-Directed Care
Out-of-Network Care
P R E V E N T I V E C A R E : Administered in accordance with Preventive Health Guidelines and PA state mandates
Preventive Care Services
 Pediatric Preventive Care
 Adult Preventive Care
Immunizations
Covered in full, waive deductible
Covered in full, waive deductible
Covered in full, waive deductible
Covered in full, waive deductible
Covered in full, waive deductible
Covered in full, waive deductible
Covered in full, waive deductible
Covered in full, waive deductible
Covered in full after deductible
Covered in full after deductible
Covered in full, waive deductible
Covered in full, waive deductible
50% coinsurance after
deductible
50% coinsurance after
deductible
50% coinsurance, waive
deductible
Mammograms
 Screening Mammogram
One per benefit period
 Diagnostic Mammogram
50% coinsurance, waive
deductible
50% coinsurance after
deductible
Gynecological Services
 Screening Gynecological Exam & Pap
Smear
One per benefit period
50% coinsurance, waive
deductible
BENEFITS LISTED BELOW APPLY ONLY AFTER BENEFIT PERIOD DEDUCTIBLE IS MET
Acute Care Hospital Room & Board
Covered in full after deductible
50% coinsurance after
deductible
50% coinsurance after
deductible
Acute Inpatient Rehabilitation
60 days/benefit period
Covered in full after deductible
50% coinsurance after
deductible
50% coinsurance after
deductible
Skilled Nursing Facility
100 days/benefit period
Covered in full after deductible
50% coinsurance after
deductible
50% coinsurance after
deductible
 Surgical Procedure & Anesthesia
Covered in full after deductible
50% coinsurance after
deductible
50% coinsurance after
deductible
Maternity Services and Newborn Care
Covered in full after deductible
Diagnostic Services
Covered in full after deductible
50% coinsurance after
deductible
50% coinsurance after
deductible
50% coinsurance after
deductible
50% coinsurance after
deductible
50% coinsurance after
deductible
50% coinsurance after
deductible
50% coinsurance after
deductible
50% coinsurance after
deductible
50% coinsurance after
deductible
50% coinsurance after
deductible
50% coinsurance after
deductible
50% coinsurance after
deductible
$40 copayment per visit
50% coinsurance after
deductible
50% coinsurance after
deductible
$40 copayment per visit
50% coinsurance after
deductible
50% coinsurance after
deductible
$40 copayment per visit
50% coinsurance after
deductible
50% coinsurance after
deductible
$40 copayment per visit
50% coinsurance after
deductible
50% coinsurance after
deductible
$40 copayment per visit
50% coinsurance after
deductible
50% coinsurance after
deductible
Surgery
 Radiology
Covered in full after deductible
 Laboratory
Covered in full after deductible
 Medical tests
Covered in full after deductible
Outpatient Surgery
Covered in full after deductible
Outpatient Therapy Services
 Physical Medicine
20 visits/benefit period
 Occupational Therapy
20 visits/benefit period
 Speech Therapy
12 visits/benefit period
 Respiratory Therapy
20 visits/benefit period
 Manipulation Therapy
20 visits/benefit period
PGOEJ504
7/1/16
Large Group – CareConnect
(7/1/2014)
SUMMARY OF BENEFITS
(CONTINUED)
Limits and
Maximums
Amounts Members Are Responsible For:
Covered in full, waive deductible
Emergency room copayment applies, waived if admitted inpatient
Emergency Services
Mental Health Care Services
 Inpatient Services
Covered in full after deductible
50% coinsurance after deductible
50% coinsurance after
deductible
 Outpatient Services
$40 copayment per visit
50% coinsurance after deductible
50% coinsurance after
deductible
Covered in full after deductible
50% coinsurance after deductible
50% coinsurance after
deductible
$40 copayment per visit
50% coinsurance after deductible
Covered in full after deductible
50% coinsurance after deductible
Durable Medical Equipment (DME)
Covered in full after deductible
50% coinsurance after deductible
Prosthetic Appliances
Covered in full after deductible
50% coinsurance after deductible
Orthotic Devices
Covered in full after deductible
50% coinsurance after deductible
Substance Abuse Services
 Rehabilitation – Inpatient
 Rehabilitation – Outpatient
Home Health Care Services
90 visits/benefit period
50% coinsurance after
deductible
50% coinsurance after
deductible
50% coinsurance after
deductible
50% coinsurance after
deductible
50% coinsurance after
deductible
BENEFITS LISTED BELOW DO NOT APPLY BENEFIT PERIOD MEDICAL DEDUCTIBLE
PRESCRIPTION DRUG DEDUCTIBLE
$100 per member (deductible does not apply to Healthy Rewards)
Per benefit period
Retail Pharmacy
(up to a 30-day supply)
Mail Service Pharmacy
(up to a 90-day supply)
Specialty Pharmacy
(up to a 30-day supply)
Generic Preferred Prescription Drugs
$3 copay
Healthy Rewards
Copay
$1.50 copay
$6 copay
Healthy
Rewards Copay
$3 copay
Generic Non-Preferred Prescription Drugs
$15 copay
$7.50 copay
$30 copay
$15 copay
$15 copay
Healthy
Rewards Copay
N/A
N/A
Brand Preferred Prescription Drugs
$35 copay
$17.50 copay
$70 copay
$35 copay
$35 copay
N/A
Brand Non-Preferred Prescription Drugs
$50 copay
$25.00 copay
$100 copay
$50 copay
$50 copay
N/A
Preventive Coverage
Covered in full, waive deductible
Network
CVS Caremark National Pharmacy Network, Include Voluntary Maintenance Choice
PRESCRIPTION DRUG TIER
(Contraceptives)-Limited Coverage*
BENEFIT
PRESCRIPTION DRUG TIER
Copay
Copay
Copay
$3 copay
Generic Prescription Drugs
Select Brand Prescription Drugs**
Brand Preferred Prescription Drugs
Brand Non-Preferred Prescription Drugs
$0 copayment
$0 copayment
$0 copayment
$0 copayment
Not covered
$35 copay
$70 copay
Not covered
$50 copay
$100 copay
Not covered
FORMULARY SYSTEM
Open
UTILIZATION PROGRAM
BENEFIT
Restrictive Generic Substitution – In addition to the coinsurance/ copayment, the member pays the difference
between the brand and generic drug price (when there is a generic alternative) unless the physician requests the
brand be dispensed.
Generic Substitution Program
Not covered
Specialty Pharmacy
For most specialty medications, coverage is available only when dispensed by Accredo Health Group, Inc.
Voluntary Maintenance Choice
The dispensing of maintenance covered drugs for up to a 90 day supply is available through Mail Service or at CVS Pharmacies
Quantity Level Limits (per prescription, day
supply or copayment)
Applicable to selected drugs. Refer to the Capital BlueCross formulary or go to www.capbluecross.com.
Prior Authorization and Enhanced Prior
Applicable to selected drugs. Refer to the Capital BlueCross formulary or go to www.capbluecross.com.
Authorization
Benefits are underwritten by Capital Advantage Insurance Company®, a subsidiary of Capital BlueCross. An independent licensee of the BlueCross BlueShield Association.
Deductibles, coinsurance and copayments under this program are separate from any deductibles, coinsurance and copayments required under any other health benefits coverage you may
have.
Inpatient admissions as well as certain other services and equipment may require preauthorization.
*Some contraceptive services are not covered by this group contract. Members may receive contraceptive benefits directly from Capital BlueCross due to the Affordable Care
Act’s mandate on women’s preventive services.
**Select Brands include contraceptives for which there is no generic equivalent.
Under CareConnect Select, you should designate a CareConnect primary care physician (PCP) from the list of PCPs in Capital’s Provider Directory. The CareConnect Select program provides
the highest level of coverage when care is provided or coordinated by your PCP. To locate a PCP or other participating provider, visit www.capbluecross.com.
Participating providers agree to accept our allowance as payment in full—often less than their normal charge.
If you visit a non-participating provider, you are responsible for paying the deductible, coinsurance and the difference between the non-participating provider’s charges and the allowable
amount. Non-Participating Providers may balance bill the member. Some non-participating facility providers are not covered.
Refer to your Certificate of Coverage or contact your employer for the applicable benefit period.
This managed care plan may not cover all your health care expenses. Read your contract carefully to determine which health care services are covered. Please call the Customer
Service number on the back of your identification card if you have any questions regarding your coverage.
On behalf of Capital BlueCross, CVS/Caremark assists in the administration of our prescription drug program. CVS/Caremark is an independent pharmacy benefit manager.
Accredo Health Group, Inc. is the exclusive vendor for specialty prescription drugs. On behalf of Capital BlueCross, Accredo Health Group, Inc. assists in the delivery of specialty
medications directly to our Members. Accredo Health Group, Inc. is an independent company.
Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.
www.capbluecross.com
Benefit Highlights
PPO 1500 Plan
Messiah College
THIS IS NOT A CONTRACT. This information highlights some of the benefits available through this program and is NOT intended to be a complete list or description of
available services. Benefits are subject to the exclusions and limitations contained in your Certificate of Coverage (COC). Refer to your COC for benefit details.
Amounts Members Ar e Responsible For:
Participating Providers
Non-Participating Providers
SUMMARY OF COST-SHARING
Deductible (per benefit period)
Copayments
 Office Visits (performed by a Family Practitioner, General Practitioner,
Internist, Pediatrician, Preventive Medicine specialist, or participating Retail
Clinic)
 Specialist Office Visit
 Emergency Room
 Urgent Care
 Inpatient (Per Admission)
 Outpatient Surgery Copayment (facility)
Coinsurance
Out-of-Pocket Maximum (includes Deductible, Copayments and Coinsurance for
Medical (including ER), and Prescription Drug for Participating Providers only).
SUMMARY OF BENEFITS
Limits and
Maximums
$1,500 per member
$3,000 per family
$3,000 per member
$6,000 per family
$15 copayment per visit
30% coinsurance
$30 copayment per visit
30% coinsurance
$150 copayment per visit, waived if admitted
$30 copayment per visit
Not Applicable
30% coinsurance
Not Applicable
30% coinsurance
10% coinsurance
30% coinsurance
$3,000 per member
$6,000 per family
$6,000 per member
$12,000 per family
Amounts Members Are Responsible For:
Participating Providers
Non-Participating Providers
P R E V E N T I V E C A R E : Administered in accordance with Preventive Health Guidelines and PA state mandates
Preventive Care Services
 Pediatric Preventive Care
 Adult Preventive Care
Immunizations
Mammograms
 Screening Mammogram
 Diagnostic Mammogram
One per benefit period
Covered in full, waive deductible
Covered in full, waive deductible
Covered in full, waive deductible
30% coinsurance after deductible
30% coinsurance after deductible
30% coinsurance waive deductible
Covered in full, waive deductible
10% coinsurance after deductible
30% coinsurance after deductible
30% coinsurance after deductible
Gynecological Services
 Screening Gynecological Exam & Pap Smear One per benefit period
Covered in full, waive deductible
30% coinsurance after deductible
BENEFITS LISTED BELOW APPLY ONLY AFTER BENEFIT PERIOD DEDUCTIBLE IS MET
30% coinsurance after deductible
Acute Care Hospital Room & Board
10% coinsurance after deductible
10% coinsurance after deductible
10% coinsurance after deductible
30% coinsurance after deductible
30% coinsurance after deductible
10% coinsurance after deductible
10% coinsurance after deductible
30% coinsurance after deductible
30% coinsurance after deductible
 Laboratory
10% coinsurance after deductible
10% coinsurance after deductible
30% coinsurance after deductible
30% coinsurance after deductible
 Medical tests
10% coinsurance after deductible
30% coinsurance after deductible
10% coinsurance after deductible
30% coinsurance after deductible
Acute Inpatient Rehabilitation
Skilled Nursing Facility
Surgery
45 days/benefit period
100 days/benefit period
 Surgical Procedure & Anesthesia
Maternity Services and Newborn Care
Diagnostic Services
 Radiology
Outpatient Surgery
Outpatient Therapy Services





Physical Medicine
Occupational Therapy
Speech Therapy
Respiratory Therapy
Manipulation Therapy
30 visits/benefit period
30 visits/benefit period
30 visits/benefit period
30 visits/benefit period
20 visits/benefit period
Emergency Services
Mental Health Care Services
 Inpatient Services
 Outpatient Services
Substance Abuse Services
 Rehabilitation – Inpatient
 Rehabilitation – Outpatient
Home Health Care Services
Durable Medical Equipment (DME)
Prosthetic Appliances
Orthotic Devices
$30 copayment per visit
30% coinsurance after deductible
$30 copayment per visit
30% coinsurance after deductible
$30 copayment per visit
30% coinsurance after deductible
$30 copayment per visit
30% coinsurance after deductible
$30 copayment per visit
30% coinsurance after deductible
Covered in full, waive deductible
Emergency room copayment applies, waived if admitted inpatient
30% coinsurance after deductible
10% coinsurance after deductible
$30 copayment per visit
10% coinsurance after deductible
90 visits/benefit period
$30 copayment per visit
10% coinsurance after deductible
10% coinsurance after deductible
10% coinsurance after deductible
10% coinsurance after deductible
30% coinsurance after deductible
30% coinsurance after deductible
30% coinsurance after deductible
30% coinsurance after deductible
30% coinsurance after deductible
30% coinsurance after deductible
30% coinsurance after deductible
Benefits are underwritten by Capital Advantage Assurance Company®, a subsidiary of Capital BlueCross. Independent licensee of the BlueCross BlueShield
Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.
PPOEJ001
7/16
Large Group – PPO Plan
(7/1/2014)
SUMM ARY OF BENEFITS
PRESCRIPTION DRUG DEDUCTIBLE
Per benefit period*
Amounts Members Ar e Responsible For:
$100 per member
Retail Pharmacy
(up to a 30-day supply)
PRESCRIPTION DRUG TIER
Generic Preferred Prescription Drugs
BENEFIT
$3 copayment
Generic Non-Preferred Prescription Drugs
Brand Preferred Prescription Drugs
Brand Non-Preferred Prescription Drugs
$15 copayment
$35 copayment
$50 copayment
Same as above
Lifestyle Drugs
Mail Service Pharmacy
(up to a 90-day supply)
Specialty Pharmacy
(up to a 30-day supply)
$6 copayment
$3 copayment
$30 copayment
$70 copayment
$100 copayment
$15 copayment
$35 copayment
$50 copayment
Same as above
Same as above
Network
PRESCRIPTION DRUG TIER
(Contraceptives)-Limited Coverage*
Generic Prescription Drugs
Select Brand Prescription Drugs**
Brand Preferred Prescription Drugs
Brand Non-Preferred Prescription Drugs
CVS Caremark National Pharmacy Network, Voluntary Maintenance Choice
FORMULARY SYSTEM
UTILIZATION PROGRAM
Generic Substitution Program
Open
BENEFIT
Restrictive Generic Substitution – In addition to the coinsurance/copayment, the member pays the
difference between the brand drug and generic drug price (when there is a generic drug alternative)
unless the prescribing physician requests that the brand drug be dispensed.
For most specialty medications, coverage is available only when dispensed by Accredo Health
Group, Inc.
The dispensing of maintenance covered drugs for up to a 90 day supply is available through Mail
Service or at CVS Pharmacies
Applicable to selected drugs. Refer to the Capital BlueCross formulary or go to
www.capbluecross.com.
Applicable to selected drugs. Refer to the Capital BlueCross formulary or go to
www.capbluecross.com.
Specialty Pharmacy
Voluntary Maintenance Choice
Quantity Level Limits (per prescription, day
supply or copayment)
Prior Authorization and Enhanced Prior
Authorization
BENEFIT
$0 copayment
$0 copayment
$35 copayment
$50 copayment
$0 copayment
$0 copayment
$70 copayment
$100 copayment
Not covered
Not covered
Not covered
Not covered
Inpatient admissions as well as certain other services and equipment may require Preauthorization.
Deductibles, coinsurance and copayments under this program are separate from any deductibles, coinsurance and copayments required under any other health benefits
coverage you may have.
*Some contraceptive services are not covered by this group contract. Members may receive contraceptive benefits directly from Capital BlueCross due to the Affordable Care
Act’s mandate on women’s preventive services.
**Select Brands include contraceptives for which there is no generic equivalent.
Participating providers and pharmacies agree to accept our allowance as payment in full—often less than their normal charge. If you visit a non-participating provider or
pharmacy, you are responsible for paying the deductible, coinsurance and the difference between the non-participating provider’s or non-participating pharmacy’s charges and
the allowable amount. Non-Participating Providers may balance bill the member. Some non-participating facility providers are not covered. Deductibles, any differences paid
between brand drug and generic drug prices, and any balances paid to non-participating pharmacies are not applied to the out-of-pocket maximum. In certain situations a
facility fee may be associated with an outpatient visit to a professional provider. Members should consult with the provider of the services to determine whether a facility fee
may apply to that provider. An additional cost sharing amount may apply to the facility fee.
On behalf of Capital BlueCross, CVS/Caremark assists in the administration of our prescription drug program. CVS/Caremark is an independent pharmacy benefit
manager. Accredo Health Group, Inc. is the exclusive vendor for specialty prescription drugs. On behalf of Capital BlueCross, Accredo Health Group, Inc. assists
in the delivery of specialty medications directly to our Members. Accredo Health Group, Inc. is an independent company.
For more information or to locate a participating provider, visit www.capbluecross.com.
Autism Spectrum Disorders are covered as mandated by Pennsylvania state law for group size >51.
PPOEJ001
7/16
Large Group – PPO Plan
(7/1/2014)
Benefit Highlights
www.capbluecross.com
PPO HSA Plan
Messiah College
THIS IS NOT A CONTRACT. This information highlights some of the benefits available through this program and is NOT intended to be a complete list or description of
available services. Benefits are subject to the exclusions and limitations contained in your Certificate of Coverage (COC). Refer to your COC for benefit details.
Amounts Members Ar e Responsible F or:
Participating Providers
Non-Participating Providers
SUMMARY OF COST-SHARING
Deductible (per benefit period)
Deductible is waived for PREVENTIVE SERVICES unless otherwise noted.
Deductible is combined to include medical & prescription drug benefits.
Copayments
 Office Visits (performed by a Family Practitioner, General Practitioner,
Internist, Pediatrician, Preventive Medicine specialist, or participating Retail
Clinic)
 Specialist Office Visit
 Emergency Room
 Urgent Care
 Inpatient (Per Admission)
 Outpatient Surgery Copayment (facility)
Coinsurance
Out-of-Pocket Maximum
Includes deductible, coinsurance and copayments for medical & prescription drug
benefits.
SUMMARY OF BENEFITS
Limits and
Maximums
$2,000 single coverage
$4,000 family coverage
$4,000 single coverage
$8,000 family coverage
10% coinsurance after deductible
30% coinsurance
10% coinsurance after deductible
30% coinsurance
10% coinsurance after deductible
10% coinsurance after deductible
30% coinsurance
Not Applicable
Not Applicable
30% coinsurance
30% coinsurance
10% coinsurance
30% coinsurance
$3,500 single coverage
$7,000 family coverage
$7,000 single coverage
$14,000 family coverage
Amounts Members Are Responsible For:
Participating Providers
Non-Participating Providers
P R E V E N T I V E C A R E : Administered in accordance with Preventive Health Guidelines and PA state mandates
Preventive Care Services
 Pediatric Preventive Care
 Adult Preventive Care
Immunizations
Mammograms
One per benefit period
 Screening Mammogram
 Diagnostic Mammogram
Gynecological Services
 Screening Gynecological Exam & Pap Smear One per benefit period
BENEFITS LISTED BELOW APPLY ONLY AFTER
Acute Care Hospital Room & Board
Covered in full, waive deductible
Covered in full, waive deductible
Covered in full, waive deductible
30% coinsurance after deductible
30% coinsurance after deductible
30% coinsurance, waive deductible
Covered in full, waive deductible
10% coinsurance after deductible
30% coinsurance, after deductible
30% coinsurance after deductible
Acute Inpatient Rehabilitation
45 days/benefit period
Covered in full, waive deductible
30% coinsurance, after deductible
BENEFIT PERIOD DEDUCTIBLE IS MET
30% coinsurance after deductible
10% coinsurance after deductible
10% coinsurance after deductible
30% coinsurance after deductible
Skilled Nursing Facility
Surgery
 Surgical Procedure & Anesthesia
Maternity Services and Newborn Care
Diagnostic Services
 Radiology
100 days/benefit period
10% coinsurance after deductible
30% coinsurance after deductible
10% coinsurance after deductible
10% coinsurance after deductible
30% coinsurance after deductible
30% coinsurance after deductible
10% coinsurance after deductible
10% coinsurance after deductible
30% coinsurance after deductible
30% coinsurance after deductible
10% coinsurance after deductible
30% coinsurance after deductible
10% coinsurance after deductible
30% coinsurance after deductible
 Laboratory
 Medical tests
Outpatient Surgery
Outpatient Therapy Services
 Physical Medicine
 Occupational Therapy
 Speech Therapy
 Respiratory Therapy
 Manipulation Therapy
Emergency Services
Mental Health Care Services
 Inpatient Services
 Outpatient Services
Substance Abuse Services
 Rehabilitation – Inpatient
 Rehabilitation – Outpatient
Home Health Care Services
Durable Medical Equipment (DME)
Prosthetic Appliances
Orthotic Devices
30 visits/benefit period
30 visits/benefit period
30 visits/benefit period
30 visits/benefit period
20 visits/benefit period
90 visits/benefit period
10% coinsurance after deductible
30% coinsurance after deductible
10% coinsurance after deductible
30% coinsurance after deductible
10% coinsurance after deductible
30% coinsurance after deductible
10% coinsurance after deductible
30% coinsurance after deductible
10% coinsurance after deductible
30% coinsurance after deductible
10% coinsurance after deductible
10% coinsurance after deductible
30% coinsurance after deductible
10% coinsurance after deductible
30% coinsurance after deductible
10% coinsurance after deductible
30% coinsurance after deductible
10% coinsurance after deductible
10% coinsurance after deductible
10% coinsurance after deductible
10% coinsurance after deductible
10% coinsurance after deductible
30% coinsurance after deductible
30% coinsurance after deductible
30% coinsurance after deductible
30% coinsurance after deductible
30% coinsurance after deductible
Benefits are underwritten by Capital Advantage Assurance Company®, a subsidiary of Capital BlueCross. Independent licensee of the BlueCross BlueShield
Association. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies.
Trans 31978
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Large Group-PPO HSA
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HIGHLIGHTS
Amounts Members Are Responsible For:
DEDUCTIBLE (Includes medical and
prescription drug benefits) Deductible is
Retail Pharmacy
(up to a 30-day supply)
Mail Service Pharmacy
(up to a 90-day supply)
Specialty Pharmacy
(up to a 30-day supply)
waived for Prescription Medications
listed on Capital’s Preventive Medication
List. Members can access this list at
capbluecross.com
PRESCRIPTION DRUG TIER
Generic Preferred Prescription Drugs
Generic Non-Preferred Prescription Drugs
Brand Preferred Prescription Drugs
Brand Non-Preferred Prescription Drugs
Lifestyle Drugs
BENEFIT
$3 copayment
$15 copayment
$35 copayment
$50 copayment
Same as above
$6 copayment
$30 copayment
$70 copayment
$100 copayment
Same as above
$3 copayment
$15 copayment
$35 copayment
$50 copayment
Same as above
Network
PRESCRIPTION DRUG TIER (Contraceptives)
Limited Coverage*
Generic Prescription Drugs
Select Brand Prescription Drugs**
Brand Preferred Prescription Drugs
CVS Caremark National Pharmacy Network, Include CVS 90
$0 copayment
$0 copayment
$35 copayment
$0 copayment
$0 copayment
$70 copayment
Not covered
Not covered
Not covered
Brand Non-Preferred Prescription Drugs
$50 copayment
$100 copayment
Not covered
FORMULARY SYSTEM
UTILIZATION PROGRAM
Generic Substitution Program
Open
BENEFIT
Restrictive Generic Substitution – In addition to the coinsurance/ copayment, the member pays the
difference between the brand and generic drug price (when there is a generic alternative) unless the physician
requests the brand be dispensed.
For most specialty medications, coverage is available only when dispensed by Accredo Health Group,
Inc.
Applicable to selected drugs. Refer to the Capital BlueCross formulary or go to
www.capbluecross.com.
Applicable to selected drugs. Refer to the Capital BlueCross formulary or go to
www.capbluecross.com.
Specialty Pharmacy
Quantity Level Limits (per prescription, day supply
or copayment)
Prior Authorization and Enhanced Prior
Authorization
BENEFIT
Inpatient admissions as well as certain other services and equipment may require Preauthorization.
Deductibles, coinsurance and copayments under this program are separate from any deductibles, coinsurance and copayments required under any other health benefits
coverage you may have.
*Some contraceptive services are not covered by this group contract. Members may receive contraceptive benefits directly from Capital BlueCross due to the Affordable Care
Act’s mandate on women’s preventive services.
**Select Brands include contraceptives for which there is no generic equivalent.
Participating providers and pharmacies agree to accept our allowance as payment in full—often less than their normal charge. If you visit a non-participating provider or
pharmacy, you are responsible for paying the deductible, coinsurance and the difference between the non-participating provider’s or non-participating pharmacy’s charges and
the allowable amount. Non-Participating Providers may balance bill the member. Some non-participating facility providers are not covered. Deductibles, any differences paid
between brand drug and generic drug prices, and any balances paid to non-participating pharmacies are not applied to the out-of-pocket maximum. In certain situations a
facility fee may be associated with an outpatient visit to a professional provider. Members should consult with the provider of the services to determine whether a facility fee
may apply to that provider. An additional cost sharing amount may apply to the facility fee.
On behalf of Capital BlueCross, CVS/Caremark assists in the administration of our prescription drug program. CVS/Caremark is an independent pharmacy benefit
manager. Accredo Health Group, Inc. is the exclusive vendor for specialty prescription drugs. On behalf of Capital BlueCross, Accredo Health Group, Inc. assists
in the delivery of specialty medications directly to our Members. Accredo Health Group, Inc. is an independent company.
For more information or to locate a participating provider, visit www.capbluecross.com.
Autism Spectrum Disorders are covered as mandated by Pennsylvania state law for group size >51.
Trans 31978
7/15
Large Group-PPO HSA
(7/1/2014)
CAPITAL BLUE CROSS VISION PLAN
If you would like to make changes to your vision coverage, please complete:
 2016-2017 Open Enrollment form, section 3
 Capital Blue Cross Enrollment Application
If you would like to newly elect vision coverage, please complete:
 2016-2017 Open Enrollment form, section 3
 Capital Blue Cross Enrollment Application
If you would like to drop vision coverage, please complete:

2016-2017 Open Enrollment form, section 3
DENTAL-GUARD PREFERRED PLAN
If you would like to make changes to your dental coverage, please complete:
 2016-2017 Open Enrollment form, section 2
 Guardian Dental Only Enrollment Form
If you would like to newly elect dental coverage, please request a Guardian enrollment packet
from Su Deitch in Human Resources and complete:
 2016-2017 Open Enrollment form, section 2
 Guardian Enrollment/ Change Form
If you would like to drop dental coverage, please complete:
 2016-2017 Open Enrollment form, section 2
The Guardian Life Insurance Company of America
Northeast Regional Office
P.O. Box 26040
Lehigh Valley, PA 18002-6040
GG-013500
Enrollment Form
For Non-Medical Coverages
Planholder Name (Company Name)
Group Plan No.
Division
Messiah College
00414842
Class
Planholder Street Address
City
State
Zip
One College Avenue, PO Box 3015
Grantham
PA
17027
MARITAL STATUS:
Single
Married
Widowed
PLEASE CHECK REASON FOR COMPLETING:
CHANGE:
ADD DEPENDENT(S)
DATE OF CHANGE
___/___/___
Legally Separated
DEPENDENT CHILDREN:
Divorced
YES
NO
INITIAL APPLICATION
TERMINATE A FAMILY MEMBER
ADDRESS
NAME
DELETE COVERAGE
REASON FOR CHANGE___________________________________________________
GIVE THE FOLLOWING INFORMATION FOR EACH PERSON TO BE INSURED
Name (Last, First, Middle Initial)
Sex
Employee:
Spouse:
Child:
Child:
Child:
Child:
(1) Are any dependent children adopted?
 Yes  No
(2) Have you included stepchildren?
 Yes  No
(3) Are they dependent on you for support and maintenance?
Date of Full Time Employment
Hrs. Worked / Week
M
F
M
F
M
F
M
F
M
F
M
F
Date of Marriage
/
Full Time
Student?
Full Time
Student?
Full Time
Student?
Full Time
Student?
/
Yes
No
Yes
No
Yes
No
Yes
No
If “yes”, indicate name and date of placement:
If “yes”, indicate name(s):
 Yes  No
Occupation /Job Title
Employee’s Street Address
State
Employee’s Social Security #
Birthdate
City
Zip
Business Phone #
Home Phone #
DENTAL
Employee:
I elect coverage.
Spouse:
Yes
No***
Child(ren):
Yes
No***
I decline coverage. I understand if I elect coverage at a later date, late entrant penalties will apply. **
** If declining coverage, are you covered under another dental plan?
Yes
No
*** If declining dependent coverage, are your dependents covered under another dental plan?
Yes
No
DECLINATION OF COVERAGE:
If I have waived the insurance, I understand that if I request coverage for myself and/or my eligible dependents at a later date, I will be required to furnish, at my own
expense, proof of each person’s insurability, and Guardian reserves the right to reject my request.
I hereby apply for the group benefit(s) indicated above.
I understand I must be actively at work or my coverage will not take effect until I have completed a waiting period (as defined in the Group Plan) of full time service.
I understand that insurance coverage for my dependents will not take effect if a dependent, other than a newborn is confined to a hospital or other health care facility,
or is unable to perform the normal activities of someone of like age and sex.
I authorize my employer to take deductions from my pay or agree that the contributions be added to my dues; if they are required for the insurance.
The information provided above is true and correct to the best of my knowledge.
Any person who with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or
deceptive statement may be guilty of insurance fraud.
X SIGNATURE OF EMPLOYEE
DATE
PLEASE RETAIN A PHOTOCOPY FOR YOUR RECORDS AND SUBMIT THIS FORM TO GUARDIAN
CEF-1999
LONG TERM CARE INSURANCE
The need for long-term care can occur at any point in your life due to illness, accident or the effects of aging.
Some of the highlights of the plan include an inflation protection feature, premiums based on age at enrollment,
premium payment available through payroll deduction and full portability of coverage. This important benefit is
available to eligible employees, spouses, parents and grandparents, parents-in-law, grandparents-in-law and
adult siblings.
You can apply for Genworth Long Term Care Insurance at any time. If you would like to apply for
this coverage, please go to:
www.genworth.com/groupltc
Group ID: MESSC
Access Code: groupltc
To speak with a Program expert, please call 1.800.416.3624
PERSONAL ACCIDENT INDEMNITY PLAN
PERSONAL CANCER INDEMNITY PLAN
PERSONAL SICKNESS INDEMNITY PLAN



The Personal Accident Indemnity Plan pays benefits to help you and your families with everyday expenses if
you become injured.
The Personal Cancer Indemnity Plan helps minimize the financial impact of cancer treatment costs and time
away from work.
The Personal Sickness Indemnity Plan pays benefits to you and your family with every day expenses related to
illness.
If you would like to enroll in any of the Aflac plans, please contact Chris Lupp, Aflac Voluntary Benefit
Specialist, at 717.695.9377 ext. 226 no later than Friday, June 3, 2016.
If you would like to drop an Aflac plan, please complete the Cancellation Notice.
MET-LIFE VOLUNTARY LIFE INSURANCE
Voluntary Term Life Insurance is available to purchase for yourself, spouse and dependent children. In
order to cover family members, you must purchase coverage for yourself.
If you would like enroll or make changes to your MetLife voluntary life insurance, please print out
the MetLife booklet or request one from Su Deitch in Human Resources and complete:



2016-2017 Open Enrollment form
Enrollment form for Messiah College
Statement of Health Form for each individual you wish to cover
MetLife® Group Life Insurance
Messiah College Plan Benefits
Explore the coverage that makes it easy to give yourself and your loved ones more
security today…and in the future.
Supplemental Term Life Insurance Coverage Options
For You
$10,000 to $500,000 in $5,000 increments to a maximum of 5
times your basic annual earnings or $500,000
For Your Spouse
$5,000 to $150,000 in $5,000 increments
For Your Dependent Children*
$2,000 to $10,000 in $2,000 increments
*Child(ren)’s Eligibility: Dependent children ages from 15 days to 19 years old, or 23 years old if a child is a full-time student, are eligible for coverage.
Monthly Costs for Supplemental Term Life Insurance
You have the option to purchase Supplemental Term Life Insurance. Listed below are your monthly rates as
well as those for your spouse (based on your age and the amount of coverage you want). Rates to cover
your child(ren) are also shown.
Age
Your Monthly Cost Per
$1,000 of Coverage
Spouse Monthly Cost Per $1,000 of
Coverage
Under 25
$0.03
$0.06
25 - 29
$0.04
$0.08
30 – 34
$0.05
$0.10
35 – 39
$0.07
$0.11
40 – 44
$0.10
$0.14
45 – 49
$0.15
$0.20
50 – 54
$0.23
$0.38
55 – 59
$0.41
$0.63
60 – 64
$0.56
$1.16
65 – 69
$1.06
$1.98
70 +
$1.71
$2.95
Cost for your
Child(ren)†
$0.11
† Covers all eligible children
1
MetLife® Group Life Insurance
Use the table below to calculate your premium based on the amount of life insurance you will need.
Example: $100,000 Supplemental Life Coverage
1. Enter the rate from the table (example age 36)
$0.07
2. Enter the amount of insurance in thousands of dollars
(Example: for $100,000 of coverage enter $100)
100
3. Monthly premium (1) x (2)
$7.00
$ ___________
___________
$ ___________
Repeat the three easy steps above to determine the cost for each coverage selected.
Features
This insurance offering from your employer and MetLife comes with a variety of added features that
can provide assistance to you and your family members today and during a difficult time.
Accelerated Benefits Option*
For access to funds during a difficult time
You can receive up to 80% of your Supplemental Term Life insurance proceeds to a maximum of $500,000
in the event that you become terminally ill and are diagnosed with less than 12 months to live. This can go a
long way toward helping your family meet medical and other related expenses at this difficult time. The
Accelerated Benefit Option is also available to spouses insured under Dependent Life insurance plans. This
option is not available for dependent child coverage.
*The Accelerated Benefits Option is subject to state availability and regulation. The accelerated life insurance benefits offered under
your certificate are intended to qualify for favorable federal tax treatment. If the accelerated benefits qualify for favorable tax treatment,
the benefits will be excludable from your income and not subject to federal taxation.
This information was written as a supplement to the marketing of life insurance products. Tax laws relating to accelerated benefits are
complex and limitations may apply. You are advised to consult with and rely on an independent tax advisor about your own particular
circumstances.
Receipt of accelerated benefits may affect your eligibility, or that of your spouse or your family, for public assistance programs such as
medical assistance (Medicaid), Temporary Assistance to Needy Families (TANF), Supplementary Social Security Income (SSI) and
drug assistance programs. You are advised to consult with social service agencies concerning the effect that receipt of accelerated
benefits will have on public assistance eligibility for you, your spouse or your family.
Conversion
For those who wish to have more permanent coverage
You can generally convert your Group Term Life insurance benefits to an Individual Whole Life insurance
policy if your coverage terminates in whole or in part due to your retirement, termination of employment, or, a
change in your employee class. Conversion is available on all Group Life insurance coverages. If you
experience an event that makes you eligible to convert your coverage, you can speak with a MetLife
representative by calling: 1-877-275-6387.
Waiver of Premiums for Total Disability (Continued Protection)
Offering continued coverage at no cost
You may be eligible to waive your Supplemental and Dependent Term Life insurance premium until you
reach age 65, die or recover from your disability, whichever is sooner, should you become unable to work
due to total disability. Total disability or totally disabled means your inability to do your job and any other job
for which you are fit by education, training or experience, due to injury or sickness. The total disability must
begin before age 60, and your waiver will begin after you have satisfied a 9-month waiting period. The
Waiver of Premium will end on the earliest of your turning age 65 death or recovery. Please note that this
benefit is available after you have participated in the Supplemental Term Life Plan for one year and it is only
available to you. This one-year requirement applies to new participants in the plan.
2
1900030220 (1208)
MetLife® Group Life Insurance
Portability
So you can keep your coverage even if you leave your current employer
Should you leave Messiah College for any reason, and your Supplemental and Dependent Term Life
insurance under this plan terminates, you will have an opportunity to continue group term coverage
(“portability”) under a different policy, subject to plan design and state availability. Competitive rates apply,
but will likely be higher than your current rates. MetLife will bill you directly. To take advantage of this feature,
you must have coverage of at least $20,000 up to a maximum of $1,000,000 .
Portability is also available on coverage you’ve selected for your spouse and dependent child(ren). The
maximum amount of coverage for spouses is $250,000; the maximum amount of dependent child coverage
is $25,000. Increases, decreases and maximums are subject to state availability.
Generally, there is no minimum time for you to be covered by the plan before you can take advantage of the
portability feature. Please see your plan administrator or certificate for specific details.
Please note that if you experience an event that makes you eligible for portable coverage, please call a
MetLife representative at 1-866-492-6983 or contact your employer for more information.
3
MetLife® Group Life Insurance
Will Preparation Service†
To ensure your decisions are carried out
Like life insurance, a carefully prepared Will is important. With a Will, you can define your most important
decisions such as who will care for your children or inherit your property. By enrolling for Supplemental
Term Life coverage, you will have access to Hyatt Legal Plans’ network of 11,000+ participating attorneys.
When you enroll in this plan, you may take advantage of this benefit at no additional cost to you if you use a
participating plan attorney.* To obtain the legal plan’s toll-free number and your company’s group access
number, contact your employer or your plan administrator for this information.
†
Will Preparation Services are offered by Hyatt Legal Plans, Inc., Cleveland, Ohio. In certain states, Will Preparation Services are
provided through insurance coverage underwritten by Metropolitan Property and Casualty Insurance Company and Affiliates, Warwick,
Rhode Island. In some states, Will Preparation is subject to regulatory approval and is not currently available.
* You also have the flexibility of using an attorney who is not participating in the Hyatt Legal Plans’ network and being reimbursed for
covered services according to a set fee schedule. In that case you will be responsible for any attorney’s fees that exceed the
reimbursed amount.
MetLife Estate Resolution Services—ERS‡
Personal service and compassion to help your beneficiaries manage your estate during their time of
need
MetLife Estate Resolution Services—is a valuable service offered at no additional cost to you.
A Hyatt Legal Plan attorney will consult your beneficiaries by telephone or in person regarding the probate
process for your estate. The attorney will also handle the probate of your estate for your executor or
administrator. You can feel confident that your executor or administrator will have access to the advice that is
needed to properly settle your estate. This can help alleviate the financial and administrative burden upon
your loved ones in their time of need.
‡
Estate Resolution Services are offered by Hyatt Legal Plans, Inc., Cleveland, Ohio. In certain states, Estate Resolution Services are
provided through insurance coverage underwritten by Metropolitan Property and Casualty Insurance Company and Affiliates, Warwick,
Rhode Island. In some states, Estate Resolution Services are subject to regulatory approval and are not currently available. The
following are not covered by the service: Matters in which there is a conflict of interest between the executor, administrator, any
beneficiary or heir and the estate; any disputes with the Policyholder, Employer, Plan Attorneys, MetLife and/or any of its affiliates; any
disputes involving statutory benefits; Will contests or litigation outside Probate Court; Appeals; Court costs, filing fees, recording fees,
transcripts, witness fees, expenses to a third party, judgments or fines; and frivolous or unethical matters.
MetLife Advice**
Assistance identifying solutions for your financial situations
MetLife Advice is a service designed to help provide assistance in making financial decisions based on the
major events in your life such as marriage, the birth of a child, purchase of a home, death of a spouse or
retirement. Contact your employer or plan administrator for more information.
**MetLife Advice Specialists are Financial Services Representatives of MetLife or New England Financial, a MetLife company.
MetLife Advice for Beneficiaries—Delivering The Promise®
For support and guidance when beneficiaries need it most
MetLife Advice for Beneficiaries—Delivering The Promise® is a service designed to provide beneficiaries with
the support and assistance they need during an especially difficult time. Services include assistance filing
life insurance claims and consultation to help with the financial details and questions that arise upon the loss
of a loved one.
4
1900030220 (1208)
MetLife® Group Life Insurance
MetLife’s Division of Estate Planning (MetDESK®)††
MetLife’s Division of Estate Planning for Special Kids (MetDESK®)
MetDESK is a service that works with families who have children with special needs to help them prepare for
the complex financial, social, emotional, and educational issues facing them. MetDESK helps families with
financial and estate planning, strategies for education, and government eligibility issues.
††
MetDESK, MetLife’s Division of Estate Planning for Special Kids. Investment advisory services offered by MetLife Securities, Inc., 200
Park Avenue, NY, NY 10166.
Total Control Account®
For immediate access to death proceeds
The Total Control Account® settlement option provides your loved ones with a safe and convenient way to
manage the proceeds of a life policy for claim payments of $5,000 or more, backed by the financial strength
and claims paying ability of Metropolitan Life Insurance Company. They'll have the convenience of
immediate access to any or all of their proceeds, through an interest bearing account with unlimited checkwriting privileges. The Total Control Account gives beneficiaries time to decide what to do with their
proceeds, which can be very helpful to them during a difficult time.
What’s Not Covered?
Like most insurance plans, this plan has exclusions. For instance, Supplemental and Dependent Life
Insurance do not provide payment of benefits for death caused by suicide within the first two years (one year
in North Dakota) of the effective date of the certificate, or payment of increased benefits for death caused by
suicide within two years (one year in North Dakota or Colorado) of an increase in coverage.
5
MetLife® Group Life Insurance
Additional Coverage Information
How To Apply*
Complete your enrollment form and return it to your Human Resources Manager today! Be sure to indicate
your Beneficiary. You may enroll for life insurance coverage quickly and securely online using the
“MyBenefits” website from MetLife. It’s easy to use. Just go to www.metlife.com/mybenefits.
Act Now During the Enrollment Period.
Note: If you do not wish to make a change to your coverage, you do not need to do anything.
*
Coverage will either be approved by MetLife based upon its underwriting rules and your answers or you will be asked to submit a
Statement of Health to complete your application for coverage.
For Employee Coverage
Enrollment in this Supplemental Term Life insurance plan is available without providing a Statement of
Health form as long as:
For Annual Enrollment
x Your enrollment takes place before the enrollment deadline and
x You are continuing the coverage you had in the last year
For New Hires
x Your enrollment takes place within 31 days from the date you become eligible for benefits, and
x You are enrolling for coverage equal to/less than $150,000
If you do not meet all of the conditions stated above, you will need to provide additional medical
information by completing a Statement of Health form. A Statement of Health is included in this booklet.
For Dependent Coverage†
Your spouse/domestic partner and dependent children also do not need to provide a Statement of
Health form as long as they are not home or hospital confined and not receiving disability payments and:
†
A domestic partner declaration may be required for those partners not registered with a government agency where such
registration is available.
For Annual Enrollment
x The enrollment takes place prior to the enrollment deadline, and
x Your spouse and child(ren) is continuing coverage s/he/they had in the last year
For New Hires
x The enrollment takes place within 31 days from the date you become eligible for benefits, and
x Your spouse is enrolling for coverage equal to/less than $$25,000
If you do not meet all of the conditions stated above, you will need to provide additional medical
information by completing a Statement of Health form. A Statement of Health is included in this booklet.
6
1900030220 (1208)
MetLife® Group Life Insurance
Who Can Be A Designated Beneficiary?
You can select any beneficiary(ies) other than your employer, and you may change your beneficiary(ies) at
any time. You can also designate more than one beneficiary.
About Your Coverage Effective Date
You must be “Actively at Work” on the date your coverage becomes effective, and your spouse and eligible
child(ren) must be performing their Normal Activities when coverage becomes effective. Coverage will
become effective on date following the receipt of your completed enrollment form for all requests that do not
require additional medical information. Requests for amounts that require additional medical information and
are not approved by the date listed above will not be effective until the first of the month following approval
from MetLife or the date that Actively at Work and Normal Activities requirements are met.
This summary provides an overview of your plan’s benefits. These benefits are subject to the
terms and conditions of the contract between MetLife and Messiah College and are subject to
each state’s laws and availability. Specific details regarding these provisions can be found in
the booklet certificate.
Life coverage is provided under a group insurance policy (Policy Form GPNP99) issued to your employer by
MetLife. Life coverage under your employer’s plan terminates when your employment ceases, when your
Life contributions cease, or upon termination of the group contract. Dependent Life coverage will terminate
when a dependent no longer qualifies as a dependent or when a dependent spouse reaches age 70. Should
your life insurance coverage terminate for reasons other than non-payment of premium, you may convert it
to a MetLife individual permanent policy without providing medical evidence of insurability.
L1009067315[exp1011][All States][DC,GU,MP,PR,VI]
Metropolitan Life Insurance Company, New York, NY
7
MetLife® Group Life Insurance
1900030220 (1208)
Metropolitan Life Insurance Company, New York, NY
ENROLLMENT FORM FOR MESSIAH COLLEGE
SECTION TO BE COMPLETED BY EMPLOYER
Name of Employer
Messiah College
Employer’s Street Address
One College Avenue
Date of Hire (Mo./Day/Yr.)
Group Customer #
141879
Report #
Sub Division
Branch
City
State
Zip Code
Employee’s Work Location
Grantham
PA
17027
Employee’s Basic Annual
Employee’s Occupation
Coverage Effective Date (Mo./Day/Yr.)
Earnings (BAE) $
Work Status:
New Hire
Active
Retired
Disabled
Hours Worked Per Week
Hourly Paid
Full-Time
Rehire
On Layoff/Leave of Absence
Salaried
Part-Time
Reason for Enrollment:
New Coverage
New Hire/First Time Eligible
Late Enrollee (Statement of Health Required)
Change in Coverage Amount Requested
Change in Enrollment Other Than Coverage Amount
Family Status Change (not applicable to new enrollments) Date (Mo./Day/Yr.)
SECTION TO BE COMPLETED BY EMPLOYEE
Name (print)
First
Middle
Address Street
Last
Social Security #
City
State
E-mail Address
Zip Code
Date of Birth (Mo./Day/Yr.)
Marital
Status:
Single
Widowed
Male
Female
Married
Divorced
Phone No. (include area code)
COVERAGE REQUEST DATA:
I have received and read a copy of my employer’s current announcement of the group plan. I want to be covered under the group plan for the benefits for
which I am or may become eligible, requested below.
I request the following coverage:
Employee Coverage
Supplemental/Optional Life
You may elect a multiple of $10,000 up to a maximum of $500,000.
Note: Amounts exceeding $150,000 require a Statement of Health form.
Amount Requested: $
Dependent Spouse Coverage
Dependent Spouse Life*
You may elect a multiple of $5,000 up to a maximum of $150,000.
Note: Amounts $25,000 require a Statement of Health form.
Amount Requested: $
Dependent Child Coverage
Dependent Child Life*
$2,000
$4,000
$6,000
$8,000
$10,000
*Amounts will be subject to state limits, if applicable.
If applying for Dependent coverage (Spouse and Child), complete section below:
Number of dependents (including spouse)
Name of Spouse (Last, First, MI)
Date of Birth
Sex (M/F)
Name(s) of Child(ren) (Last, First, MI)
Date of Birth
Sex (M/F)
Is child a full-time student?
Yes
Yes
Yes
Yes
GEF02-1
ADM
Please Retain A Copy of The Fully-Completed Form For Your
Records And Return The Original To Your Employer
(Continued on Following Page)
1
Messiah College (05/09)
DECLARATION SECTION
Each person signing below declares that all the information given in this enrollment form, including any medical questions, is true and complete to the best
of his/her knowledge and belief. Each person understands that this information will be used by MetLife to determine his or her insurability.
The employee declares that he or she is actively at work on the date of this enrollment form and, for purposes of any contributory life insurance, that he or
she was actively at work for at least 20 hours during the 7 calendar days preceding the date of enrollment. In addition if the employee is not actively at work
on the scheduled Effective Date of contributory life insurance, such insurance will not take effect until the employee returns to active work.
On the date dependent insurance for a person is scheduled to take effect, the dependent must not be confined at home under a physician’s care, receiving
or applying for disability benefits from any source, or Hospitalized. If the dependent does not meet this requirement on such date, the insurance will take
effect on the date the dependent is no longer confined, receiving or applying for disability benefits from any source, or Hospitalized.
For the Accelerated Benefits Option
Life Insurance may include an Accelerated Benefits Option under which a terminally ill insured can accelerate a portion of his or her life insurance amount.
Receipt of accelerated benefits may affect eligibility for public assistance and an interest and expense charge may be deducted from the accelerated
payment.
For Changes Requested After Initial Enrollment Period Expires
I understand that if life coverage is not elected, or if the maximum coverage is not elected, evidence of insurability satisfactory to MetLife may be required
to elect or increase such coverage after the initial enrollment period has expired. Coverage will not take effect, or it will be limited, until notice is received
that MetLife has approved the coverage or increase.
For Payroll Deduction Authorization By the Employee
I authorize my employer to deduct the required contributions from my pay for the coverage requested in this enrollment form. This authorization applies to
such coverage until I rescind it in writing.
Fraud Warning:
If you reside in or are applying for insurance under a policy issued in one of the following states, please read the applicable warning.
New York [only applies to Accident and Health Benefits (AD&D/Disability/Dental)]: Any person who knowingly and with intent to defraud any
insurance company or other person files an application for insurance containing any materially false information, or conceals for the purpose of
misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to
a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.
Florida: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a statement of claim or an application
containing any false, incomplete or misleading information is guilty of a felony of the third degree.
Kansas, Oregon, and Vermont: Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any
fact material thereto may be guilty of insurance fraud, and may be subject to criminal and civil penalties.
Massachusetts: Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material
thereto commits a fraudulent insurance act, and may subject such person to criminal and civil penalties.
New Jersey: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and
civil penalties.
Oklahoma: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an
insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Puerto Rico: Any person who, knowingly and with the intent to defraud, presents false information in an insurance request form, or who
presents, helps or has presented, a fraudulent claim for the payment of a loss or other benefit, or presents more than one claim for the same
damage or loss, will incur a felony, and upon conviction will be penalized for each violation with a fine no less than five thousand (5,000) dollars
nor more than ten thousand (10,000), or imprisonment for a fixed term of three (3) years, or both penalties. If aggravated circumstances prevail,
the fixed established imprisonment may be increased to a maximum of five (5) years; if attenuating circumstances prevail, it may be reduced to
a minimum of two (2) years.
Virginia and Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the
purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
GEF02-1a
DEC
(Continued on Following Page)
2
All other states: Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance or a statement of claim containing any materially false information or conceals, for the purpose of misleading, information
concerning any fact material thereto commits a fraudulent insurance act, which may be a crime and may subject such person to criminal and
civil penalties.
BENEFICIARY DESIGNATION FOR EMPLOYEE INSURANCE (Dependent Insurance is Payable to the Employee)
The Employee signing below names the following person(s) as primary beneficiary(ies) for any MetLife payment upon his or her death. For any other
type of beneficiary, please use a beneficiary designation form available from your employer. The Employee understands that he or she has the right to
change this designation at any time.
Primary Beneficiary Full Name
Date of Birth
Share
Relationship
Address (Street, City, State, Zip)
(Last, First, Middle Initial)
(Mo./Day/Yr.)
%
Payment will be made in equal shares or all to the survivor unless otherwise indicated.
TOTAL:
100%
If the Primary Beneficiary(ies) die before me, I designate as Contingent Beneficiary(ies):
Contingent Beneficiary Full Name
(Last, First, Middle Initial)
Date of Birth
(Mo./Day/Yr.)
Relationship
Address (Street, City, State, Zip)
Payment will be made in equal shares or all to the survivor unless otherwise indicated.
TOTAL:
Share
%
100%
Signature(s): The employee must sign in all cases. The person signing below acknowledges that they have read and understand the statements and
declarations made in this enrollment form.
Sign
Here
Employee Signature
GEF02-1a
DEC
Print Name
3
Date Signed (Mo./Day/Yr.)
INSTRUCTIONS
FOR THE STATEMENT OF HEALTH FORM AND THE AUTHORIZATION FORM THAT FOLLOW THIS SECTION
INSTRUCTIONS TO THE RECORDKEEPER (The Recordkeeper may be the Group Customer, a Third Party Administrator or MetLife.)
1. Fill in the Group Customer Information and Insurance Information on the Statement of Health form.
2. Give the forms to the Employee.
INSTRUCTIONS TO THE EMPLOYEE
1. Fill in your name and Social Security Number on the Statement of Health form. The Employee's Name and the Employee’s Social Security Number must appear on the
form.
2. Give the forms to the Proposed Insured to complete and send to MetLife.
INSTRUCTIONS TO THE PROPOSED INSURED (The Proposed Insured is the person for whom insurance is being requested. The Proposed Insured may be the
Employee, the Employee’s Spouse or the Employee’s Child.) A separate Statement of Health form must be completed by each Proposed Insured.
Based on the enrollment form submitted by the Employee, a Statement of Health form is required to complete the employee’s request for group insurance coverage for
you, the Proposed Insured.
1. The Employee should fill in the Employee's name and Social Security Number and give the form to you.
Metropolitan Life Insurance Company
2. Complete the Statement of Health form and sign where indicated by an arrow.
Statement of Health Unit
3. Sign the Authorization form where indicated by an arrow.
P.O. Box 14069
Lexington, KY 40512-4069
4. After completion, make a copy of both completed forms for your records and FAX or MAIL the original forms to:
FAX: 1-859-225-7909
For questions, call MetLife at 1-800-638-6420, prompt 1 (Statement of Health Unit) or email us at [email protected].
Note: Additional medical information may be required after MetLife’s initial review of a completed Statement of Health form. The additional information requested may be a
physical examination, paramedical exam, or an Attending Physician Report. Correspondence will be sent within ten days by MetLife or our approved vendor. Incomplete
forms will be returned to you for completion.
Some services in connection with your Statement of Health form may be performed by our affiliate, MetLife Global Operations Support Center Private Limited. This service
arrangement in no way alters Metropolitan Life Insurance Company's obligations to you. Services will not be performed by our affiliate if prohibited by state or local law or
by mutual agreement with the Group Customer.
►
STATEMENT OF HEALTH FORM
Metropolitan Life Insurance Company, New York, NY
GROUP CUSTOMER INFORMATION (To be Completed by the Recordkeeper)
Name of Group Customer/Employer/Association
Street Address
Group Customer #
City
Reporting Location #
State
INSURANCE INFORMATION (To be Completed by the Recordkeeper)
Zip Code
Enrollment year
Term Life Insurance
Basic Life: Indicate amount subject to medical underwriting $
Supplemental/Optional Life: Indicate amount subject to medical underwriting $
Dependent Spouse 1 Life: Indicate amount subject to medical underwriting $
Dependent Child Life: Indicate amount subject to medical underwriting $
EMPLOYEE INFORMATION (To be Completed by the Employee)
Name of Employee (First, Middle, Last)
Social Security # of Employee
YOUR INFORMATION (To be Completed by the Proposed Insured)
Name (First, Middle, Last)
Street Address
Date of Birth (MM/DD/YYYY)
1
City
Daytime Phone #
Home Phone #
Relationship to Employee
Self
Spouse
Child
State
Male
Female
Zip Code
Email Address
For Vermont and Washington State residents, Spouse includes your registered Domestic Partner if you and your Domestic Partner are registered as
domestic partners, civil union partners or reciprocal beneficiaries with a government agency or office where such registration is available.
GEF02-1
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Page 1 of 4
SOH-XDP100M-NW (03/13)
HEALTH INFORMATION
Please complete all questions below. Omitted information will cause delays. In this section, “you” and “your” refers to the person for whom
insurance is being requested.
Your name
Employee’s Social Security/Identification #
1. Your height
feet
inches
Your weight
pounds
Yes
No
2. Are you now on a diet prescribed by a physician or other health care provider? If “yes” indicate type
3. Are you now pregnant? If “yes,” what is your due date (month/day/year)?
4. Are you now, or have you in the past 5 years, used tobacco in any form?
5. In the past 5 years, have you received medical treatment or counseling by a physician or other health care provider for, or been
advised by a physician or other health care provider to discontinue, the use of alcohol or prescribed or non-prescribed drugs?
6. In the past 5 years, have you been convicted of driving while intoxicated or under the influence of alcohol and/or any drug?
If “yes”, specify ”date(s) of conviction(s) (month/day/year)
7. Have you had any application for life, accidental death and dismemberment or disability insurance declined, postponed, withdrawn,
rated, modified, or issued other than as applied for?
8. Are you now receiving or applying for any disability benefits, including workers’ compensation?
9. Have you been Hospitalized as defined below (not including well-baby delivery) in the past 90 days?
Hospitalized means admission for inpatient care in a hospital; receipt of care in a hospice facility, intermediate care facility, or long
term care facility; or receipt of the following treatment wherever performed: chemotherapy, radiation therapy, or dialysis.
10. Have you ever been diagnosed or treated by a physician or other health care provider for Acquired Immunodeficiency Syndrome
(AIDS), AIDS Related Complex (ARC) or the Human Immunodeficiency Virus (HIV) infection?
11. Have you ever been diagnosed, treated or given medical advice by a physician or other health care provider for:
Yes
No
cardiac or cardiovascular disorder?
stroke or circulatory disorder?
high blood pressure?
cancer, Hodgkins disease, lymphoma or tumors? Indicate type
anemia, leukemia or other blood disorder? Indicate type
diabetes? Your age at diagnosis?
Check if insulin treated
asthma, COPD, emphysema or other lung disease? Indicate type
ulcers, stomach, hepatitis or other liver disorder? Indicate type
colitis, Crohn’s, diverticulitis or other intestinal disorder? Indicate type
memory loss?
epilepsy, paralysis, seizures, dizziness or other neurological disorder?
Specify date of last seizure (month/year)
Indicate type
l. Epstein-Barr, chronic fatigue syndrome or fibromyalgia?
m. multiple sclerosis, ALS or muscular dystrophy?
n. lupus, scleroderma, auto immune disease or connective tissue disorder?
o. arthritis?
osteoarthritis
rheumatoid
other/type
p. back, neck, knee, spinal, joint or other musculosketal disorder?
q. carpal tunnel syndrome?
r. kidney, urinary tract or prostate disorder? Indicate type
s. thyroid or other gland disorder? Indicate type
t. mental, anxiety, depression, attempted suicide or nervous disorder?
u. sleep apnea
For “yes” answers, please provide full details on the next page in Section 2, then complete Section 3. If all questions are answered “no,” you
may proceed directly to Section 3 on the next page.
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
GEF09-1
HEA
Page 2 of 4
SOH-XDP100M-NW (03/13)
SECTION 2 – Please provide full details below for each “Yes” answer to the preceding questions 1- 11. If you need more space to provide full
details, attach a separate sheet with the information and sign and date it. Delays in processing your application may occur if complete details are not
provided. MetLife may contact you for additional or missing information.
Question Number
Condition/Diagnosis
Date of Diagnosis (Month/Year)
Date of Last Treatment (Month/Year)
Treating Health Professional
Personal Physician’s Name:
Date of last visit:
Address
Street
Telephone: (
)
-
Reason for visit:
City
Question Number
Condition/Diagnosis
Date of Diagnosis (Month/Year)
Date of Last Treatment (Month/Year)
Treating Health Professional
Personal Physician’s Name:
Date of last visit:
Address
Street
Telephone: (
)
-
State
Zip Code
State
Zip Code
State
Zip Code
Medication Prescribed
Yes
No
Type of Treatment
Reason for visit:
City
Question Number
Condition/Diagnosis
Date of Diagnosis (Month/Year)
Date of Last Treatment (Month/Year)
Treating Health Professional
Personal Physician’s Name:
Date of last visit:
Address
Street
Telephone: (
)
-
Medication Prescribed
Yes
No
Type of Treatment
Medication Prescribed
Yes
No
Type of Treatment
Reason for visit:
City
SECTION 3
1. Personal Physician’s Name:
Telephone: (
)
–
Telephone: (
)
–
Address (Street, City, State, Zip Code):
Date of last visit (MM/DD/YYYY):
2. Are you currently taking any other prescribed medications?
Medication:
Reason for visit:
Yes
No
Condition/Diagnosis:
Prescribing Physician’s Name:
Address (Street, City, State, Zip Code):
GEF09-1
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Page 3 of 4
SOH-XDP100M-NW (03/13)
FRAUD WARNINGS
Before signing this Statement of Health form, please read the warning for the state where you reside and for the state where the contract under which you
are applying for coverage was issued.
Alabama, Arkansas, District of Columbia, Louisiana, Massachusetts, New Mexico, Ohio, Rhode Island and West Virginia: Any person who
knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty
of a crime and may be subject to fines and confinement in prison.
Colorado: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or
attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of
an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of
defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to
the Colorado Division of Insurance within the Department of Regulatory Agencies.
Florida: Any person who knowingly and with intent to injure, defraud or deceive any insurance company files a statement of claim or an application
containing any false, incomplete or misleading information is guilty of a felony of the third degree.
Kentucky: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance containing any
materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act,
which is a crime.
Maine, Tennessee, Virginia and Washington: It is a crime to knowingly provide false, incomplete or misleading information to an insurance
company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
Maryland: Any person who knowingly or willfully presents a false or fraudulent claim for payment of a loss or benefit or who knowingly or willfully presents
false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
New Jersey: Any person who files an application containing any false or misleading information is subject to criminal and civil penalties.
New York (only applies to Accident and Health Benefits): Any person who knowingly and with intent to defraud any insurance company or other person files
an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information
concerning any fact material thereto, commits a fraudulent insurance act, which is a crime, and shall also be subject to civil penalty not to exceed five
thousand dollars and the stated value of the claim for each such violation.
Oklahoma: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an
insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Oregon and Vermont: Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject
to penalties under state law.
Puerto Rico: Any person who knowingly and with the intention to defraud includes false information in an application for insurance or files, assists or abets
in the filing of a fraudulent claim to obtain payment of a loss or other benefit, or files more than one claim for the same loss or damage, commits a felony and
if found guilty shall be punished for each violation with a fine of no less than five thousand dollars ($5,000), not to exceed ten thousand dollars ($10,000); or
imprisoned for a fixed term of three (3) years, or both. If aggravating circumstances exist, the fixed jail term may be increased to a maximum of five (5)
years; and if mitigating circumstances are present, the jail term may be reduced to a minimum of two (2) years.
Pennsylvania and all other states: Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information concerning any fact
material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
GEF09-1
FW
DECLARATIONS AND SIGNATURES
By signing below, I acknowledge:
1. I have read this Statement of Health form and declare that all information I have given, including any health information, is true and complete to the best
of my knowledge and belief. I understand that this information will be used by MetLife to determine my insurability.
2. I have read the applicable Fraud Warning(s) provided in this Statement of Health form.
Sign
Here
Signature of Proposed Insured
Print Name
Date Signed (MM/DD/YYYY)
If a child proposed for insurance is age 18 or over, the child must sign this Statement of Health. If the child is under age 18, a Personal Representative for
the child must sign, and indicate the legal relationship between the Personal Representative and the proposed insured. A Personal Representative
for the child is a person who has the right to control the child’s health care, usually a parent, legal guardian, or a person appointed by a court.
Sign
Here
Signature of Personal Representative
Print Name
Date Signed (MM/DD/YYYY)
Relationship of Personal Representative
GEF09-1
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Page 4 of 4
SOH-XDP100M-NW (03/13)
AUTHORIZATION
This Authorization is in connection with an enrollment in group insurance and information required for underwriting and claim purposes for the
proposed insured(s)("employee", spouse, and any other person(s) named below). Underwriting means classification of individuals for
determination of insurability and / or rates, based upon physician health reports, prescription drug history, laboratory test results, and other
factors. Notwithstanding any prior restriction placed on information, records or data by a proposed insured, each proposed insured hereby
authorizes:
 Any medical practitioner, facility or related entity; any insurer; MIB, Group Inc. ("MIB"); any employer; any group policyholder, contract holder or benefit
plan administrator; any pharmacy or pharmacy related service organization; any consumer reporting agency; or any government agency to give
Metropolitan Life Insurance Company (“MetLife”) or any third party acting on MetLife's behalf in this regard:
 personal information and data about the proposed insured including employment and occupational information;
medical information, records and data about the proposed insured including information, records and data about drugs prescribed, medical test
results and sexually transmitted diseases;
 information, records and data about the proposed insured related to alcohol and drug abuse and treatment, including information and data records
and data related to alcohol and drug abuse protected by Federal Regulations 42 CFR part 2;
 information, records and data about the proposed insured relating to Acquired Immunodeficiency Syndrome (AIDS) or AIDS related conditions
including, where permitted by applicable law, Human Immunodeficiency Virus (HIV) test results;
 information, records and data about the proposed insured relating to mental illness, except psychotherapy notes; and
 motor vehicle reports.
Note to All Heath Care Providers: The Genetic Information Nondiscrimination Act of 2008 (GINA) prohibits employers and other entities covered by GINA
Title II from requesting or requiring genetic information of an individual or family member of the individual, except as specifically allowed by this law. To
comply with this law, we are asking that you not provide any genetic information when responding to this request for medical information. 'Genetic
information' as defined by GINA, includes an individual's family medical history, the results of an individual's or family member's genetic tests, the fact that an
individual or an individual's family member sought or received genetic services, and genetic information of a fetus carried by an individual or an individual's
family member or an embryo lawfully held by an individual or family member receiving assistive reproductive services.
Expiration, Revocation and Refusal to Sign: This authorization will expire 24 months from the date on this form or sooner if prescribed by law. The
proposed insured may revoke this authorization at any time. To revoke the authorization, the proposed insured must write to MetLife at P.O. Box 14069,
Lexington, KY 40512-4069, and inform MetLife that this Authorization is revoked. Any action taken before MetLife receives the proposed insured's
revocation will be valid. Revocation may be the basis for denying coverage or benefits. If the proposed insured does not sign this Authorization, that
person's enrollment for group insurance cannot be processed.
By signing below, each proposed insured acknowledges his or her understanding that:
 All or part of the information, records and data that MetLife receives pursuant to this authorization may be disclosed to MIB. Such information may also
be disclosed to and used by any reinsurer, employee, affiliate or independent contractor who performs a business service for MetLife on the insurance
applied for or on existing insurance with MetLife, or disclosed as otherwise required or permitted by applicable laws.
 Medical information, records and data that may have been subject to federal and state laws or regulations, including federal rules issued by Health and
Human Services, setting forth standards for the use, maintenance and disclosure of such information by health care providers and health plans and
records and data related to alcohol and drug abuse protected by Federal Regulations 42 CFR part 2, once disclosed to MetLife or upon redisclosure by
MetLife, may no longer be covered by those laws or regulations.
 Information relating to HIV test results will only be disclosed as permitted by applicable law.
 Information obtained pursuant to this authorization about a proposed insured may be used, to the extent permitted by applicable law, to determine the
insurability of other family members.
 A photocopy of this form is as valid as the original form. Each proposed insured has a right to receive a copy of this form.
 I authorize MetLife, or its reinsurers, to make a brief report of my personal health information to MIB.
Sign
Here
Signature of Proposed Insured
Print Name
Date Signed (MM/DD/YYYY)
State of Birth
Country of Birth
If a child proposed for insurance is age 18 or over, the child must sign this Authorization form. If the child is under age 18, a Personal Representative for the
child must sign, and indicate the legal relationship between the Personal Representative and the proposed insured. A Personal Representative for
the child is a person who has the right to control the child’s health care, usually a parent, legal guardian, or a person appointed by a court.
Sign
Here
Signature of Personal Representative
Print Name
Date Signed (MM/DD/YYYY)
Relationship of Personal Representative
AUTH-XDP110M-NW (03/13)
FLEXIBLE SPENDING ACCOUNTS
Discovery Benefits will administer the Flexible Spending Accounts beginning July 1, 2016.
A health care FSA is used to reimburse out-of-pocket medical, dental and vision expenses incurred by you and your
dependents. The maximum that you can contribute to the Health Care Flexible Spending account is $2,550. You can
carry over up to $500 of unused contributions into the following plan year.
A dependent care FSA is used to reimburse expenses related to care of eligible dependents while you and your spouse (if
married) work. The maximum that you can contribute to the Dependent Care Flexible Spending Account is $5,100 if you
are a single employee or married filing jointly, or $2,550 if you are married and filing separately. There is no grace period
or carryover for Dependent Care. It is a “use or lose” plan.
Enrollment DOES NOT carry over from year to year. If you wish to participate in either of these
accounts you must enroll again.
You can contribute up to $2,550.00 to the Health Care Flexible Spending Account.
You can contribute up to $5,000 to the Dependent Care Account.
If you are enrolled in the Capital Blue Cross High Deductible/Health Savings Account plan, you
CANNOT enroll in the Health Care Flexible Spending Account.
If you would like to enroll or re-enroll in the Health Care Spending Account and/or Dependent
Care Spending Account, please complete the items listed below.
The Health Care Account allows you to carry over up to $500.00 from your existing balance into
the new plan year. Any balance over the $500 will be forfeited.
The Dependent Care Account does NOT allow any carry over and does NOT have a grace period.
Any balance in the plan will be forfeited.


2016-2017 Open Enrollment form, section 6
Flexible Spending Account Enrollment Form
www.DiscoveryBenefits.com
866-451-3399 ∙
866-451-3245
PO Box 2926 ∙ Fargo, ND 58108-2926
[email protected]
Flexible Spending Account (FSA) Data Collection Worksheet
Please complete and submit this worksheet to your employer. This is an internal document used by your employer for data
collection purposes. Worksheets submitted to Discovery Benefits will not be processed.
*=Required Fields
Step 1: Participant Information
*Employer Name (Do not abbreviate)
Employee ID Number
-
-
*Participant Name (First, MI, Last)
*Social Security Number
*Participant Mailing Address
*City
Email Address
Day Telephone
*State
-
*Date of Birth (mm/dd/yyyy)
*Hire Date (mm/dd/yyyy)
*Gender (M/F)
*Zip
-
*Martial Status (Married/Single)
Step 2: Employee Premiums
If you have a payroll deduction for insurance premiums, eligible premiums will be deducted before taxes are calculated. You will
automatically be enrolled in this portion of your Section 125 Plan. However, if you wish, you may opt out of the Employee Premium
Conversion part of the Plan by contacting your HR Department and filling out the waiver form. Note: Insurance premiums are not
eligible for reimbursement with your Medical or Limited Medical Spending Account.
Step 3: Enrollment and Election Information
*Plan Type (If enrolled in an HSA, you are not eligible to enroll in the Medical
FSA. However, you are eligible for both the Limited Medical FSA and Dependent
Care FSA if offered through your employer.)
Medical FSA
Limit set by employer
Dependent Care
Account
Limit set by employer
up to IRS maximum
Limited FSA
Limit set by employer
if this plan type is
offered
*Annual Election (if employer funded, note “ER” next to amount):
$
$
$
*Number of Pay Periods (if enrolling mid-year, please enter the number of
remaining pay periods within the plan year):
÷
÷
÷
*Per Pay Period Amount (to be deducted each pay period):
=
=
=
*Date of First Payroll (mm/dd/yyyy):
*Participant Effective Date (mm/dd/yyyy):
*Pay Frequency (please check one):
Monthly
SemiMonthly
Bi-Weekly Bi-Weekly Weekly
24
26
Other
Step 4: Authorization
I authorize my employer to reduce my pay on a per-pay-period basis as indicated above. I understand my reduction is for one flex
plan year and that I cannot change or revoke my election unless I experience a qualifying event in accordance with Internal Revenue
Code Section 125 and submit my request within a reasonable amount of time as deemed by the IRS and my employer. I am aware
of the plan’s forfeiture provision and that my Social Security and federal unemployment benefits may be reduced because of my
reduced salary for tax purposes. Further, I authorize the release of any information necessary to substantiate claims submitted
against my Flexible Spending Account.
*Participant Signature
*Date
Step 5: Refusal (Note: Only complete this step if you are NOT electing to enroll in a Flexible Spending Account)
Participant Signature
Date
Revised 9/14/15
HEALTH SAVINGS ACCOUNT
For those who enroll in the High Deductible/HSA Plan, the College will contribute to a Health Savings Account
on your behalf. You can use the Health Savings Account provided through www.mybenefitwallet.com or an
account at the financial institution of your choice.
The College contribution is based on whether you enroll in individual coverage or family (you plus at least one
other person) coverage. The total annual College contribution will be made to your account in midJuly rather than quarterly.
If you elect health coverage for yourself only, the College will contribute $900 to your Health Savings
Account. You can have a total of $3350 contributed to your plan which means you can contribute up to
$2450 on a pretax basis in addition to the College contribution.
If you elect employee/child(ren), employee/spouse or family coverage, the College will contribute $1800.
annually You can have a total of $6650 which means you can contribute up to $4850 on a pretax basis in
addition to the College contribution..
If you wish to contribute to the Health Savings Account, you must complete:
 2016-2017 Open Enrollment form, section 6
 HSA Contribution Form
HSA Contribution Form
Instructions: Use this form to elect your contributions to your HSA. This may be a one-time contribution or to
set up automatic contributions to be withheld each pay.
PERSONAL INFORMATION
<Enter Name>
Employee Name:
Social Security #:
<Enter SSN>
Phone Number:
<Enter Phone>
CONTRIBUTION INFORMATION
Frequency: ☐ Per Pay (Amount: $ <Enter Amt>
☐ One-Time (Amount: $ <Enter Amt>
)
Pay Date: <Enter Date>
)
HSA ACCOUNT INFORMATION
Bank Name: <Enter Name>
Bank Routing #:
<Enter #>
HSA Account # (if available):
<Enter #>
Name on Account: <Enter Name>
Account Type:
☐ Checking ☐ Savings
SIGNATURE
By signing this document, I acknowledge that it is my responsibility (1) to determine whether I am eligible to
make contributions to my HSA and (2) to determine whether the contributions to this HSA have exceeded the
applicable maximum annual contribution limit as outlined below.
Employee Contribution Limit (2016 Tax Year)
This is the maximum contribution allowed minus the Messiah contribution.
If you are 55+, you can contribute an additional $1,000
Employee Only
$2,450
Employee+Child(ren)
$4,950
Employee+Spouse
$4,950
Family
$4,950
I authorize the above specified contribution amount to be deducted from my pay and deposited in my Health
Savings account specified above.
Employee Signature:
_HSA Contribution Form
Date:
<Enter Date>
Revised: 06/2015
ENHANCED TUITION REDUCTION
If you would like to use the Enhanced Tuition Reduction benefit for the 2016-2017 academic year, you
must make that election during open enrollment. Please complete:

2016-2017 Open Enrollment form
ALL FORMS ARE DUE TO SU DEITCH IN HUMAN RESOURCES (BOX 3015)
NO LATER THAN
FRIDAY, JUNE 3, 2016
If you have questions, please contact Su Deitch at x7085 or [email protected].