GBS DLL booklet 2016_Flip

Your
2016
Benefits
Guide
De Lage Landen Financial Services, Inc.
DLL Finance, LLC
AGCO Finance
Philips Medical Capital, LLC
And other entities

Welcome to
the DLL
Benefits
Guide!
De Lage Landen (DLL) understands the importance of
benefits to you and your family and the peace of mind that
comes from having a high-quality benefits plan. The DLL
Benefits Plan is competitive and comprehensive and offers
you a full array of benefits that allow you to choose the level of
coverage that best meets the needs of you and your family.
This Benefits Brochure is a summary of the benefits
provided by DLL and does not provide all details regarding
the benefits plans. For additional information, please refer
to the Summary Plan Descriptions (SPDs) that can be
accessed on the United States Human Resources TrueBlue
website or in the library section on the benefits website
DLLbenefits.com.
Benefits details are provided in the official plan document
for each plan, including, if applicable, plan documents and
insurance contracts.
This Benefits Guide does not constitute or imply a contract
of employment, nor does it guarantee the continuation
of DLL benefit programs. DLL reserves the right to amend
or terminate any or all provisions of the benefits plan at
any time.
This document is an outline of the coverage proposed by the carrier(s), based on information provided by De Lage Landen Financial Services,
Inc. It does not include all of the terms, coverage, exclusions, limitations, and conditions of the actual contract language. The policies and
contracts themselves must be read for those details. Policy forms for your reference will be made available upon request.
The intent of this document is to provide you with general information regarding the status of, and/or potential concerns related to, your current
employee benefits environment. It does not necessarily fully address all of your specific issues. It should not be construed as, nor is it intended to
provide, legal advice. Questions regarding specific legal issues should be addressed by an attorney who specializes in this practice area.

Contents:
– Benefits Basics 4
– General Enrollment Information 7
– Income Protection 10
– Medical Insurance Coverage 14
– Medical Prescription Coverage 15
– Wellness 17
– Accident and Critical Illness Insurance 18
– Flexible Spending Accounts (FSA) 19
– Dental Insurance Coverage 23
– Vision Plan Highlights 24
– Additional Benefits 25
– Employee Cost Sheet – Biweekly 26
– Required Annual Employer Health
Plan Notification 27
– Premium Assistance Under Medicaid and
the Children’s Health Insurance Program(CHIP) 28
– References and Resources 30
– Human Resources Call Tree 31
This Benefits Guide is an overview of the benefits
provided by DLL and does not provide all details
regarding the benefits plans. For additional information,
please refer to the Summary Plan Descriptions (SPDs)
that can be accessed on the United States Human
Resources TrueBlue website or in the library section
on the benefits website DLLbenefits.com.
Benefits details are provided in the official plan
document for each plan, including, if applicable,
plan documents and insurance contracts.
This Benefits Guide does not constitute or imply a
contract of employment, nor does it guarantee the
continuation of DLL benefit programs. DLL reserves
the right to amend or terminate any or all provisions of
the benefits plan at any time.
3

2016 DLL Benefits Guide
Benefits Basics
Benefits Open Enrollment: 2016 Plan Year
All employees (also referred to as “members”) who are
covered under the benefits plans have the opportunity to
review and make changes to current benefits elections
during the annual benefits open enrollment period,
normally in the fall of each year. For example, you can
cancel your medical coverage or enroll in a Flexible
Spending Account. Elections made during the benefits
open enrollment period will become effective on January
1 and will stay in place through December 31, unless you
or your eligible dependent experiences a Qualified Life
Event. Please refer to page 8 for a description of what to
do if you have a Qualified Life Event.
Eligibility
All full-time employees and part-time employees who
are scheduled to work at least 30 hours per week are
eligible to be covered under the company’s health and
welfare benefits plans. Coverage is effective the first of
the month after your date of hire (also known as your
“eligibility date”). Eligible employees have 31 days from
their eligibility date to make elections for the health and
welfare benefits.
Reminder: Eligibility — Eligibility for
coverage is effective the first of the
month after your date of hire. You can
decline or waive certain benefits.
DLL provides you with certain basic benefits
automatically – some require election, and you can also
decline or waive certain benefits. All eligible employees
are eligible for the following benefits on the first of the
month following date of hire:
––
Medical/Prescription Coverage
––
Dental Coverage
––
Vision Coverage
––
Flexible Spending Accounts
––
Basic and Supplemental Life/AD&D Insurance
––
401(k) Retirement Savings Plan
––
Basic Short-Term Disability
––
Employee Assistance Plan
––
Basic Long-Term Disability
––
Prepaid Legal Plan
––
Accident Coverage
––
Critical Illness
Independent Contractors, Management Trainees,
Temporary Employees and Interns/Co-ops are not
eligible to participate in any of the DLL benefits plans.
Newly eligible employees have 31 days from their
eligibility date to make their elections for the health and
welfare benefits. Please note that payroll deductions for
contributions begin as soon as administratively feasible.
Coverage Categories
You may choose one of the following four coverage
categories when you decide whom to cover under the
Medical, Vision and Dental plans:
––
Employee
––
Employee & Child(ren)
––
Employee & Spouse/Domestic Partner
––
Family
4

Domestic Partnership with Businessolver, DLL’s benefits
service administrator. Additional life insurance
can also be purchased for a domestic partner
(Supplemental Life Insurance).
Dependent Coverage
Eligible dependents include:
––
An employee’s legal spouse (same or
opposite gender)
––
An employee’s domestic partner and eligible
dependent child(ren) of the domestic partner
(by birth, adoption or legal guardianship).
––
Children, step-children and adopted children from
birth to age 26.
––
A disabled child to any age.
––
A child subject to a Qualified Medical Child Support
Order (QMCSO) – a court order that gives an
otherwise ineligible child a right to coverage under
the Medical Plan, Dental Plan, Vision Plan and
Healthcare Spending Account.
No person may be covered both as an employee and
a dependent, and no person may be covered as a
dependent of more than one employee.
Reminder: Eligibility — Children, stepchildren
and adopted children from birth
to age 26 are eligible dependents.
Domestic Partner Coverage
A domestic partner is a person (of the same or opposite
gender) who:
––
Shares the same principal residence with you.
––
Shares financial responsibilities with you, such as
co-ownership of property, joint financial accounts,
medical expenses.
––
Is at least 18 years old.
––
Is not legally married to another person.
Please note that under applicable federal income tax law,
payments for medical, vision or dental coverage of a
domestic partner may not be eligible for pretax treatment.
In addition, coverage of the domestic partner may result in
additional imputed taxable income (imputed value tax) to
the covered member, and related withholding for payroll
taxes (including income and social security taxes) by DLL.
The imputed value tax is calculated by comparing the
member’s premium prior to adding a domestic partner,
with the premium after adding the domestic partner. The
difference between the two is the imputed value tax that is
added to the member’s subject taxable wages. For further
information on imputed value tax, please refer to Internal
Revenue Code (IRC) Section 152 rule.
When Coverage Ends
If your employment with DLL ends and you are no
longer an active member of the company, coverage for
some of the benefits provided by DLL will end on your
last day of employment and some will end on the last
day of the month in which your employment ends.
Please refer to each benefit type for details on when
coverage ends.
Consolidated Omnibus Budget Reconciliation
Act (COBRA)
When your employment with DLL ends, you will be
offered temporary continuation of health coverage at
group rates under COBRA. To be eligible for COBRA
coverage, you must have been enrolled in the DLL
health plan while employed, and the health plan must
continue to be in effect for active members.
For members who elect to cover a domestic partner,
you and your partner must complete an Affidavit of
Enrollment of Domestic Partners to certify that you
meet the criteria. A domestic partner and eligible
dependent children of the partnership who live with you
are eligible for medical/prescription/vision and dental, as
long as you and your domestic partner meet the
conditions of and also file the Affidavit for Enrollment of
5

2016 DLL Benefits Guide
6

General Enrollment Information
Benefits Confirmation Statements
When you are finished making your
benefits elections online, you will
have an opportunity to “Review and
Submit” all of your benefit elections,
payroll deductions, dependents and
beneficiary information. To accept
your benefits elections, click
“APPROVE” at the bottom of the
page. Your elections will not be
saved until you click “AGREE.” The
system will then create a benefits
election confirmation statement for
you to print and retain for your
records, and a copy will also be sent
to your home. Members may view
their individual Benefit Summary
online by clicking Benefits followed
by Benefits Summary when logged
into the system.
Businessolver
Businessolver is our benefits service platform with a DLL Benefits Call
Center providing members access to a dedicated benefits support team
who can take your benefits elections over the phone and answer
questions about benefits. The system provides members with an
enhanced and easy to use online tool to review all benefit-related
information, make benefits decisions, and easily enroll in those benefits
at www.DLLbenefits.com.
New Employees
You can enroll in benefits through Businessolver either online or over the
telephone within the first 31 days of your eligibility date (first of the month
after your date of hire). If you do not enroll within 31 days of your eligibility
date, you will need to wait until the next annual benefits “open enrollment”
period to make your elections, unless you or your dependent experiences
a Qualified Life Event. Please refer to page 8 for a description of what to do
if you have a Qualified Life Event.
Open Enrollment
Once a year, during the DLL benefits “open enrollment” period, you will have
the opportunity to review and make changes to your current benefits
elections. Keep in mind that Flexible Spending Accounts (FSA) require annual
elections. It is recommended that you review your election for your Health
Savings Account annually as the federal contribution maximums may have
changed.. Your benefits elections during open enrollment can be made
online at DLLbenefits.com or over the telephone. Participants covered
under COBRA may also make changes during the benefits open enrollment
period. Employees on qualified leave of absence will be notified by mail.
How to Access Benefits
There are two ways to enroll
— Call Businessolver at 855 851 6801 to speak directly to a benefits representative.
— Log on to DLLbenefits.com. Once you have logged in, click `Start Here’ and follow the instructions to enroll in your benefits or waive coverage.
Important Note:
You will be asked to use the employee self serve system at DLLbenefits.com to review and make all of your 2016 elections. To
ensure coverage for your dependents, please be sure to add their social security number. Call the DLL Benefits Service Center
at 855 851 6801 if you have any questions.
Businessolver Benefits Call Center
Benefits representatives at Businessolver’s Benefits Call Center are available to help you with questions you may have about your benefits during
benefits open enrollment - or anytime during the year.
Call The Benefits Call Center at 855 851 6801 to:
— Enroll or change your benefits and update your dependent and beneficiary information.
— Find out what benefits you are eligible for and get confirmation of your benefits coverage.
— Reset your online Benefits Call Center password or get support to navigate the benefits website.
— Get help with benefits claims and eligibility questions.
— Obtain ID cards, forms, and contact information for service providers, such as the medical insurance company.
DLLbenefits.com
The DLL benefits website is your online resource to confirm your benefit coverage, review benefit plan details and obtain benefits claims forms. This
functional online tool puts your benefits at your fingertips.
With just a few clicks you can:
— Review benefits plan documents and resources.
— Enroll in your benefits during the designated enrollment period.
— Review current benefits elections for your entire family.
— Make changes based on a Qualified Life Event.
— Update your life insurance beneficiaries.
— Get help with benefits claims and eligibility questions.
— Obtain ID cards, forms, and contact information for service providers, such as the medical insurance company.
7

2016 DLL Benefits Guide
Paying for Coverage
DLL pays the full cost of your Basic Life Insurance, Basic
Short-Term Disability Insurance, Basic Long-Term
Disability Insurance and Employee Assistance Program
(EAP). You and the company share the cost of some of
your benefits, such as medical/prescription, vision and
dental, and your share of the cost depends on the
plan option and coverage category you choose. Your
contributions are normally applied throughout the
year through payroll deductions.
Reminder: Open Enrollment — Each fall,
there is an annual open enrollment
period when eligible employees can
change their benefits elections for the
next benefits plan year.
Benefit Elections
Qualified Life Events
If you or your dependent experiences a Qualified Life Event,
you may make certain changes to your benefits during the
year, outside of the open enrollment period. You may only
make benefits changes that are consistent with the nature
of your Qualified Life Event. For example, if you get married,
you may add your new spouse to the benefits plan, but you
may not change from one medical plan to another.
Important Note: It is important to notify Businessolver within 31
days of your Life Event if you wish to change
your benefits! If you do not make changes
within 31 days of each Life Event, you will be
required to wait until the next open enrollment
to make changes.
Qualified Life Events include:
––
Change in status, including marital status, eligibility for
domestic partner coverage, number of
dependents, employment
––
status, residence, or a dependent ceases to satisfy
eligibility requirements.
––
Open enrollment of dependent’s employer.
––
Significant cost or coverage changes to DLL
benefits plan.
––
HIPAA special enrollment rights.
––
FMLA special requirements.
––
Change due to a judgment, decree, or court order.
––
Entitlement to Medicare or Medicaid.
The following chart details DLL benefits and how the
costs are allocated:
Benefit
Basic Life/AD&D
Insurance
Basic Short-Term
Disability
Basic Long-Term
Disability
Employee Assistance
Program
Medical/
Prescription
Who
Contributes?
DLL
DLL
DLL
DLL
DLL & You
Tax
Treatment
N/A
N/A
N/A
N/A
Pretax*
Dental DLL & You Pretax*
Supplemental Life/ You
After Tax
AD&D Insurance
Flexible Spending You
Pretax*
Accounts
Health Savings
DLL & You
Pretax*
Account
401(k) Plan DLL & You Pre- and After Tax
Pre-Paid Legal Plan You After Tax
Auto/Homeowners You
After Tax
Insurance
Pet Insurance You After Tax
Vision DLL & You Pretax*
Accident You After Tax
Critical Illness You After Tax
* Under applicable federal income tax law, payments for medical or
dental coverage of a domestic partner may not be eligible for
pretax treatment. Please refer to Domestic Partner Coverage
section for more information.
8

Pre-Tax Contributions
Pretax Contributions are contributions taken from your
pay before federal income taxes, Social Security taxes
and, in some cases, state income taxes are withheld
from your pay. The effect of this is that your taxable pay
is reduced by the contribution amounts, resulting in a
tax savings. Consider consulting a personal tax advisor
regarding the potential effect of pretax contributions on
your future Social Security benefits.
Leave of Absence
Your participation in the benefits plans will not be
affected if you are granted a paid leave of absence by
the company. As long as you remain on DLL’ s active
payroll and are receiving a paycheck from the
company, you will continue to be eligible for coverage
under the health and welfare plans. If you are on an
unpaid leave of absence, you will be required to
continue to share the cost of applicable benefits, and
you will be required to pay your benefits contributions.
9

2016 DLL Benefits Guide
Income Protection
To help protect your family financially in case something
happens to you, the company offers a number of
options that allow you to choose the coverage that
best meets your needs.
––
Basic Life Insurance pays benefits to your
beneficiaries when you die.
––
Basic Accidental Death & Dismemberment (AD&D)
Insurance pays a benefit to you or your beneficiary.
––
Supplemental Life Insurance and AD&D may be
purchased for yourself. You may also purchase
additional Life Insurance for your spouse/domestic
partner and child(ren).
––
Short-Term Disability Insurance provides full or partial
payment of your earnings during periods of shortterm
absence from work that is due to a disability.
––
Long-Term Disability Insurance provides 60% of your
earnings if you are disabled and unable to work.
Basic Life Insurance
DLL provides a Basic Life Insurance benefit for
members equal to one times your annual earnings to a
maximum benefit of $400,000 at no cost to you. You are
automatically covered under the Basic Life Insurance
plan; however, you must designate a beneficiary. If your
annual earnings increase during the year, your basic life
insurance benefit that will be paid to your beneficiary will
be the same as your new earnings.
Federal law requires you to be taxed on the value (not
the amount) of employer-paid life insurance that is
greater than $50,000. This value is referred to as
imputed income. To avoid this additional tax, you may
instruct DLL to cap your Basic Life Insurance benefit at
$50,000. If you elect to have DLL cap your Basic Life
Insurance benefit at $50,000 and wish to receive the full
benefit at a later date, you will be subject to evidence of
insurability on the increased Life Insurance benefit.
Beneficiary
You must designate a beneficiary for your Basic Life
Insurance (you can have more than one beneficiary).
You may change your beneficiary at any time. If there is
no surviving beneficiary at the time of your death,
payment of benefits will be made to survivors in the
following order:
1. Spouse
2. Your child or children
3. Your parents
4. Your estate
10

Employee Life Insurance
A member can purchase additional life insurance for
himself or herself in $10,000 increments to a maximum
of $500,000; Guarantee Issue of the lesser of $250,000
or 3 x earnings when first eligible for the benefit, and you
must designate a beneficiary.
Basic Employee Accidental Death &
Dismemberment Insurance (AD&D)
Accidental Death & Dismemberment Insurance
provides additional financial protection to you or your
family in the event of accidental death, dismemberment,
blindness or loss of speech or hearing due to an
accident. DLL provides an Accidental Death &
Dismemberment Insurance benefit equal to one times
your annual earnings to a maximum benefit of
$400,000. This benefit is provided in addition to your
Basic Life Insurance. If you instruct DLL to cap your
Basic Life Insurance benefit to $50,000, your Basic
AD&D benefit will be subject to the same limit as well.
Important Note:
Your life and AD&D benefit may reduce
depending on your age.
Supplemental Life/Accidental Death &
Dismemberment (AD&D) Insurance
To help protect your family’s financial security, you can
purchase additional Life/AD&D Insurance for yourself,
and additional Life Insurance for your spouse/domestic
partner and dependent children.
Additional Coverage for Employees and
Dependents of Employees
In order to elect additional Life Insurance coverage for a
spouse/domestic partner, members must enroll in
Employee Supplemental Life Insurance. Also, the
Supplemental Life Insurance amount you elect for your
spouse/domestic partner cannot be more than 50% of
your Employee Supplemental Life Insurance amount.
For example, if you elect Supplemental Life Insurance
for yourself of $100,000, the Supplemental Life
Insurance for your spouse/domestic partner cannot
be more than $50,000.
You may only change your life insurance benefit at Open
Enrollment each year unless you experience a life event.
Employee AD&D Insurance
A member can purchase additional AD&D Insurance for
himself or herself in $10,000 increments to a maximum
of $500,000.
Spouse/Domestic Partner Life Insurance
A member can purchase additional life insurance for a
spouse/domestic partner in $5,000 increments to the
lesser of $250,000 or 50% of the employee benefit;
Guarantee Issue of $20,000 when first eligible; the
member is the beneficiary for spouse/domestic partner
coverage and must also purchase employee coverage.
Dependent Child(ren) Life Insurance
A member can purchase additional life insurance for
dependent child(ren) in $1,000 increments to lesser of
$10,000 or 50% of the employee benefit; Guarantee
Issue of $10,000; the member is the beneficiary for
dependent coverage and must also purchase
employee coverage.
When Coverage Ends
Your Life Insurance and AD&D coverage ends when any
of the following occurs:
––
Your employment with the company ends.
––
The group policy is terminated.
Reminder: Supplemental Life Insurance
— In order to elect Supplemental Life
Insurance for a Spouse/Domestic
Partner, members must enroll in
Employee Supplemental Life Insurance.
Also, the Supplemental Life Insurance
amount you elect for your spouse
cannot be more than 50% of your
Employee Supplemental Life Insurance
amount. For example, if you elect
Supplemental Life Insurance for yourself
of $100,000, the Supplemental Life
Insurance for your Spouse/Domestic
Partner cannot be more than $50,000.
11

2016 DLL Benefits Guide
Continuous Years
of Service
Weeks Paid at 100%
Base Salary
Weeks Paid at 60%
Base Salary
0-1 0 25 25
1-2 3 22 25
2-3 6 19 25
3-4 9 16 25
4-5 12 13 25
5-6 15 10 25
6-7 18 7 25
7-8 21 4 25
8-9 24 1 25
9+ 25 0 25
Total Weeks
Paid
Basic Short-Term Disability (Disability) Insurance
The Basic Short-Term Disability (STD) benefit provides
you with income if you are unable to work due to a
non-work related injury or illness for more than five
consecutive workdays. You will be automatically enrolled
in the Basic Short-Term Disability benefit and DLL
will pay the full cost of coverage. After a five-day
elimination period, you may receive up to 25 weeks of
compensation at 100% or 60% of earnings depending
on your length of service as outlined in the Basic
Short-Term Disability Benefit Schedule below. The
disability benefit continues to the earlier of recovery or
exhaustion of the benefit. The basic disability benefit
will be offset by other income benefits including statemandated
disability benefits.
When Coverage Ends
Your Short-Term Disability Insurance coverage ends:
––
When your employment with the company ends for
any reason other than your disability.
––
The group policy is terminated for any reason.
If your employment ends while you are on short-term
disability, your disability benefits will be paid to you for as
long as you are eligible and certified as disabled. Your
medical, vision and dental coverage will continue while you
are disabled as long as you are on active payroll and continue
to pay your current monthly benefit contributions.
Once LTD benefits begin, your employment with
DLL terminates
Basic Long-Term Disability (LTD) Insurance
The Basic Long-Term Disability (LTD) benefit provides
eligible members a benefit of 60% of annual earnings to a
maximum of $12,000 per month. The benefit begins after
180 days of disability and continues to the earlier of
recovery or retirement (even if your employment with DLL
terminates). The Basic LTD premium that DLL pays on your
behalf is not treated as taxable income, so the benefit is
taxable to you when paid.
When Coverage Ends
Your LTD coverage ends on the earliest of the following
dates:
––
When your employment ends for any reason other
than your disability.
––
The LTD plan is terminated for any reason.
12

2016 DLL Benefits Guide
Medical Insurance Coverage
The health and well being of you and your family is
important to DLL. DLL recognizes that, for many
people, medical coverage is the most important benefit,
and DLL is choosing to lead the market by subsidizing
the majority of the cost of your medical coverage. DLL
is partnered with Independence Blue Cross powered by
Highmark. DLL will continue to offer three plans: Blue
Cross EPO, Blue Cross PPO and Blue Cross HDHP
with HSA.
Important Note:
Preventive care is covered 100% at no cost to
you — no copays, no deductibles.
What is the Blue Cross Exclusive Provider
Organization (EPO) Plan?
The EPO is a more restrictive type of preferred provider
organization plan under which employees must use
providers from the specified network of physicians and
hospitals to receive coverage; there is no coverage for
care received from a non-network provider except in an
emergency situation. You do not have to select a PCP,
and you may go directly to any network provider
without a referral.
What is the Blue Cross Preferred Provider
Organization (PPO) Plan?
The PPO gives you preferred benefits when you use
providers who participate in the PPO network. Through
the PPO plan, you have the freedom to choose how
you access your health care. You do not have to select
a PCP, and you may go directly to any participating
provider (network provider) without a referral. You
may also visit nonparticipating providers at the nonpreferred
level of benefits, under which you are
responsible for paying a deductible and coinsurance
amount. It is recommended that you use network
providers to maximize the plan’s in-network benefit
schedule. Network providers are preferred providers
who have contractual arrangements with the plan to
provide medical services at a reduced rate.
What is the Blue Cross High Deductible Health Plan
with Health Savings Account (HDHP with HSA)?
The HDHP with HSA is a plan design similar to the PPO
plan with both in-network and out-of-network coverage,
giving you the freedom to choose how you access your
health care. You must meet your individual or family
deductible before the schedule of benefits begins.
By enrolling in a qualified high deductible health plan you
may be eligible to open an HSA account. The HDHP with
HSA gives you more control over how you spend, or
save, your health care dollars. It is a medical plan and a
savings account all in one. You can save for future
medical expenses by allowing your HSA funds to remain
in the account and earn interest, or you can use your
debit card to get instant access to your HSA dollars to
pay for qualified out-of-pocket expenses quickly and
easily. If the money in your HSA is used for qualified
medical expenses, it is tax-free upon withdrawal. DLL
will make biweekly contributions to your HSA, and the
amount and frequency that DLL contributes may vary
by year. You may make additional contributions on a
pretax basis into your HSA, subject to the IRS annual
HSA contribution limit. Members age 55 and over can
make an additional HSA catch-up contribution up to the
IRS limit. For additional information about HSAs,
including annual contribution limits, please refer to
IRS Publication 969 (www.irs.gov).
Important Note:
When you are using a lab for a blood draw, it is
important that you confirm the lab you are
utilizing is in the Blue Cross network. You can
check the current in-network labs at any time
on mybenefitshome.com. If you have blood
taken in your doctor’s office it will be
considered in-network as long as your
physician is in the network.
Deductible
The deductible is the dollar amount of covered
expenses you must pay before the medical plan starts
paying benefits. For example, if the plan has a $200
deductible, you pay the first $200 of your covered
expenses each year and this is referred to as “meeting
the plan deductible”. Once you have met the deductible,
the plan pays part of a covered expense and you pay the
rest (your copayment).
Copayment
A copayment (copay) is a flat fee that you pay each time
you receive certain in-network covered services, for
example doctor’s office visits.
14

Reminder: The FutureScripts IBC Prescription
Drug Program will provide
members the ability to fill a prescription
for a 90 day supply at retail or mail order.
Members are no longer required to fill
their maintenance prescriptions at mail
order. Members will still have the mail
order option providing the convenience
of having prescriptions sent directly to
your home.
Reminder: Pre-certification — Prior to a
planned inpatient admission or within 48
hours of an emergency or maternityrelated
inpatient admission be sure to
verify that your provider is obtaining
precertification. If your provider will not,
you are responsible for contacting for
precertification. If this does not occur and
it is later determined that all or part of the
inpatient stay was not medically necessary
or appropriate, you will be responsible for
payment of any costs not covered.
Medical Prescription Coverage
DLL and Blue Cross are working together to help
minimize the effect of rising healthcare costs. In order
to provide quality drugs at affordable prices, Blue Cross,
in partnership with FutureScripts, provides the following
prescription tier level:
––
Formulary Generic
––
Formulary Brand-Name
––
Non-Formulary Brand-Name
Members and their eligible dependents enrolled in a DLL
medical plan are covered under the FutureScripts
Prescription Plan. When using the FutureScripts network
retail pharmacy, there is a copay based on the
prescription tier level. FutureScripts will offer a 90 day
supply for maintenance medications at certain retail
pharmacies and will also continue to offer the mail order
option. The mail order program is not a mandatory
program, but offered as a convenience for members.
Maintenance medications are defined as medications
that individuals must use on a consistent basis for the
treatment of chronic health conditions, such as asthma
or diabetes. The 90 day supply options provide you with a
three-month supply of medication for two copays.
Health Claims Procedure
Claim forms may be obtained at mybenefitshome.com
or on the United States Human Resources TrueBlue
website. If your claim is denied in whole or in part, you
will receive written notification of the denial from IBC
and DLL (the Medical Plan Sponsor). The notice
will explain the reason for the denial and the review
procedures. You may appeal the denial of the claim
by following the claim appeal process.
When Coverage Ends
Your medical, dental and vision coverage ends:
––
On the last day of the month in which your
employment ends
––
When you no longer make the required contributions
to participate in the plan
––
When you voluntarily elect to cancel your coverage
due to a change in your status
––
The company terminates group health benefits
Your dependent’s medical, dental and vison
coverage ends:
––
When your coverage ends or the company
terminates group health benefits
––
You fail to make required contributions for coverage
––
Your dependent no longer qualifies as a dependent
under the plan
Important Note:
Members can choose medical coverage only,
dental coverage only, vision coverage only or a
combination of the three.
15

2016 DLL Benefits Guide
Benefit
Deductible
Single
Family
Blue Cross HDHP/HSA
In/Out Of-Network
$1,500 3 /$1,700
$3,000 3 /$3,700
Blue Cross EPO
In-Network Only
N/A
N/A
Blue Cross PPO
In/Out Of-Network
N/A/$230
N/A/$700
Co-Insurance 100%/80% N/A 100%/80%
Out-of-Pocket Max
Single
Family
Includes ded. & co-ins.
$3,000/$3,000
$6,000/$6,000
$3,000
$6,000
Includes ded. & co-ins.
$4,000/$4,000
$8,000/$8,000
Office Visits
Primary Care Physician
Specialist
$20, after deductible 1 /80% 1
$25 copay
$25, after deductible 1 /80% 1 $35 copay
Preventive Care 2 100% 100% 100%
$25 copay/80% 1
$30 copay/80% 1
Other Services
Chiropractic Care
Emergency Room
Urgent Care
Hospitalization
Outpatient Surgery
$25, after deductible 1 /80% 1
$35 copay
$50 after deductible 1 /80% 1
$150 copay
waived if admitted
waived if admitted
$25, after deductible 1
$65
$100, after deductible 1 /80% 1 $175 for the first 5 days
$100, after deductible 1 /80% 1 $175 copay
$30 copay/80% 1
$100 copay/80% 1
waived if admitted
$50
$130 for the first 5 days/80% 1
$130 copay/80% 1
Radiology
Facility Standard
Facility Advanced 4
Professional Standard
Professional Advanced 4 $20, after deductible 1 / 80% 1
$50, after deductible 1 / 80% 1
$10, after deductible 1 / 80% 1
$25, after deductible 1 / 80% 1 $50 copay
$70 copay
$25 copay
$35 copay
$20 copay/80% 1
$50 copay/80% 1
$10 copay/80% 1
$25 copay/80% 1
Prescription Drugs
Retail:
Formulary Generic
Formulary Brand-Name
Non-Formulary Brand-Name
$5 copay, after deductible
$20 copay, after deductible
$45 copay, after deductible
$10 copay
$30 copay
$45 copay
$10 copay
$25 copay
$45 copay
Mail Order:
Formulary Generic
Formulary Brand-Name
Non-Formulary Brand-Name
$10 copay, after deductible
$40 copay, after deductible
$90 copay, after deductible
$20 copay
$60 copay
$90 copay
$20 copay
$50 copay
$90 copay
Dependent Children
Age Limit To age 26 To age 26 To age 26
1 After deductible.
2 For further information including a complete list of preventive services, please go to DLLbenefits.com
3 DLL will contribute $700 if you are enrolled as employee only and $1,350 if you are enrolled in any other tier, into your Health Savings Account.
4 Advanced Radiology includes MRI, CAT Scan, PET Scan, etc.
Blue Distinction Centers and Blue Distinction Centers Plus Enhanced Benefit
If a member chooses to use one of these centers for one of these six services that will have the following cost share
compared to using a non-qualifying facility for the specific services.
Bariatric SurgeryCenters
Cardiac Care
Complex and Rare Cancer
Knee/Hip Replacement
Spine Surgery
Transplant
HDHP Plan EPO Plan PPO Plan
100% after deductible
100%,
100%, Out of Network (OON):
Out of Network: No Coverage Out of Network: No Coverage
OON Level
BDC/BDC+ Providers:
BDC/BDC+ Providers:
BDC/BDC+ Providers:
100% after deductible
100% Coverage
100% Coverage
Non BDC Providers:
Non BDC Providers:
Non BDC Providers:
$100 copay, after deductible $175 Per day, 5 day max
$130 Per day, 5 day max
Out of Network (OON):
Out of Network (OON):
Out of Network (OON):
OON Level
No Coverage
OON Level
100% after deductible
100%, Out of Network:
100%, Out of Network (OON):
Out of Network: No Coverage No Coverage
OON Level
16

Wellness
Wellness Reward - Don’t miss your opportunity to
participate! Program available to employees only enrolled
in the medical plan. If you complete and submit the following
plus you enroll in the medical plan in 2017 you will receive the
wellness reward of $500 starting Janaury 1, 2017.
––
Complete the Wellness Profile with Blue Cross
––
Participate in the Biometric Screenings
––
Visit your doctor for your annual physical exam
––
Certify the completion of a preventive service that may
include a dental exam, mammogram, colonoscopy,
prostate exam, pap smear exam, vision exam.
Additional information on how you can achieve these goals
throughout the year will be communicated, so it is important
that you look for this information.
17

2016 DLL Benefits Guide
Accident and Critical
Illness Insurance
An accident or illness can be unexpected and costly. In
fact, 37.9 million annual emergency room visits alone are
related to injuries. Despite having medical coverage,
many people are not adequately prepared for out-ofpocket
expenses that follow.
Certain critical illnesses are becoming more prevalent,
but so are survival rates, thanks to recent medical
breakthroughs and early detection. Many people
underestimate the financial impact of a critical illness,
especially on lost income. Despite having good medical
coverage, many are not adequately prepared financially
when faced with a serious illness.
New this year, DLL will offer employees the chance to
purchase accident and/or critical illness coverage on a
post-tax basis. Benefit will be a tax free lump sum cash
payment should an employee have an accident or critical
illness.
Important Note: Your accident and critical illness benefit may
reduce depending on your age.
Example Accident Benefit
Example Critical Illness Benefit
(must be at least 45 years old)
Benefit Low Plan High Plan Benefit $15,000 $30,000
Fractured Ankle Surgery $250 $500 Cancer $15,000 $30,000
Hospital Admission (non-ICU) $500 $1,000 Heart Attack $15,000 $30,000
X-Rays (MRI) $100 $200
Appliance (crutches) $50 $100
TOTAL BENEFIT $900 $1,800 TOTAL BENEFIT
Family Premium Example Low Plan High Plan Family Premium Example $15,000 $30,000
Annual Premium $298 $575 Annual Premium $678 $1,356
Wellness Benefit
(2 members with a
wellness screenings)
$100 $200 Wellness Benefit
(2 members with a
wellness screenings)
$100 $200
Net Out of Pocket Premium
with Wellness Screening
$198 $375 Net Out of Pocket Premium
with Wellness Screening
$578 $1,156
18

Flexible Spending Accounts
(FSA)
Flexible Spending Accounts allow you to pay for certain
out-of pocket healthcare and dependent care expenses
with pretax dollars. Each year, you may elect to deposit
pretax funds from your pay for deposit into a Flexible
Spending Account for either medical/dental/Rx/vision
expenses or eligible dependent care expenses. You
choose the amount that you want deducted from each
paycheck, and the maximum amount that you can set
aside varies by the type of FSA as explained in the next
section. Keep in mind that the contribution amount you
elect remains in effect throughout the calendar year,
unless you have a “Qualified Life Event.” See page 8
for details on a Qualified Life Event.
Reminder: FSA — Each year you must
enroll in the Flexible Spending Accounts if
you want to participate in the upcoming
Plan Year.
Businessolver Administers DLL’ Flexible
Spending Accounts (FSA)
A Visa debit card will be provided to each member who
elects this benefit and it can be used for qualified
purchases. You can use the debit card to pay for your
eligible expenses, or you may pay out-of-pocket and
submit a claim for reimbursement. When you use the
debit card, it is important that you retain your receipts
as you may be asked to substantiate certain claims.
For more detailed information about expense eligibility,
please refer to the IRS Publication 502 and IRS
Publication 503 (www.irs.gov).
Medical Flexible Spending Account (Medical FSA)
The Medical FSA allows you to reduce your taxable
income by setting aside funds for qualified medical
expenses for you and your family. You may contribute
between $100 and $2,500 to a Medical FSA and use it
to pay for medical, prescription, dental, and vision
expenses that are not covered by insurance.
Procedures considered cosmetic are not eligible
expenses. The total amount elected for the year is
available on the first day of eligibility.
Reminder: You will receive a new debit
card if your card expires in 2016.
Limited Purpose Medical Flexible Spending Account
(for HDHP with a Health Spending Account (HSA)
participants ONLY)
Important Note:
Federal regulations mandated that the
maximum amount an employee can contribute
on a pre-tax basis to a health care FSA is
$2,500.
Members enrolled in the HDHP are eligible to participate
in the Limited Purpose Medical FSA, which can be used
for qualified dental and vision expenses. The Limited
Purpose Medical FSA may not be used for medical and
prescription expenses. HDHP participants will need to
use their Health Savings Account for medical and
prescription expenses. Procedures considered
cosmetic are not eligible expenses. You may contribute
between $100 and $2,500 to your Limited Purpose
Medical FSA. The total amount elected for the year is
available for you to use on the first day of eligibility.
The three types of Flexible Spending Accounts offered
by DLL are the Medical Flexible Spending Account, the
Limited Purpose Medical Flexible Spending Account
and the Dependent Care Flexible Spending Account.
The FSA deduction is made before income taxes are
calculated; therefore, you pay no income tax on
these expenses.
19

2016 DLL Benefits Guide
Dependent Care Flexible Spending Account
(Dependent Care FSA)
The Dependent Care FSA allows you to reduce your
taxable income by certain qualified childcare expenses.
You may contribute between $100 and $5,000 to a
Dependent Care FSA and use it to pay for qualified
childcare and elder care expenses. You can use the
debit card to pay for your eligible expenses or pay for
them and submit a claim for reimbursement.
To be eligible to participate in the Dependent Care
FSA, both parents must work outside of the home, and
the child must be under 13 years of age. Single parents
may participate as well. Per the IRS, the maximum
election is $5,000 for a married individual filing a joint
return or a single parent, or $2,500 for a married
individual filing a separate return.
Reminder: FSA — You cannot transfer
money between Flexible Spending
Accounts, and the FSA funds can only be
used for reimbursement toward eligible
FSA expenses for which you are enrolled.
Availability of FSA Funds and When You Can File Claims
You can be reimbursed for qualifying expenses up to the
annual amount you elected at enrollment for your
Medical FSA even if the full amount has not yet been
deducted from your paychecks. Please note that you
cannot transfer money between Flexible Spending
Accounts, and the funds can only be used for
reimbursement toward eligible FSA expenses for which
you are enrolled. For example, if you elect contributions
to a Medical FSA, it can only be used for reimbursement
toward eligible medical, prescription, dental and vision
expenses. For more detailed information about expense
eligibility, please refer to IRS Publication 502 and 503.
501 and IRS Publication 503 (www.irs.gov).
You can submit claims at any time for any amount. When
you submit a claim for reimbursement, you must submit
acceptable evidence to support your claim. If your claim is
denied, you will be notified in writing within 90 days after
Businessolver receives the claim, and the notice will
include the specific reason for the denial and a description
of any additional supporting documentation required.
The Tax Advantage
Your payroll deductions for your FSA are made before
income taxes are calculated; therefore you pay no
income tax on these expenses. Below is an example
that considers how much you have to earn to pay for
expenses with after-tax dollars versus before-tax dollars.
With Healthcare Account
Before-Tax Dollars
Cost of eye glasses $125 $125
Taxes you pay on earnings* $0 $49
Earnings required to purchase eye glasses $125 $174
Without Healthcare Account
Before-Tax Dollars
*Assumes federal income tax bracket of 28%
20

What happens while on a Leave
of Absence?
Medical and Limited Purpose Medical FSA
Your participation in the Medical and Limited Purpose
Medical FSA will not be affected if you are granted a paid
leave of absence by the company. Payroll deductions will
continue and you will continue to be able to use your
Flexible Medical Spending Account. If you are on an
unpaid leave of absence, your payroll contributions will
be suspended, however, you can still participate using
after-tax dollars and you can apply for reimbursement
for eligible expenses. When you return to work, your FSA
contributions will resume on a pretax basis provided you
return to the company in the same year in which your
leave of absence began. If you return to work for the
company in a subsequent year, you will have to re-enroll
in the Medical or Limited Purpose Medical FSA during
the annual benefits open enrollment period.
Dependent Care FSA
Your participation in the Dependent Care FSA will be
suspended during a leave of absence. Current federal
law does not allow you to participate in the Dependent
Care FSA during any period that you are not working,
and you cannot be reimbursed for any expenses
incurred during a leave of absence. You can resume
Dependent Care FSA contributions if you return to work
in the same year in which your leave of absence began. If
you return to work in a subsequent year, you will have to
re-enroll in the Dependent Care FSA during the annual
open enrollment.
Features for FSA Claim Submission, Online
and Mobile Tools
If you have qualifying expenses that were not paid using
your benefit card, you have three options for submitting
these expenses for reimbursement:
1. You can upload your claim online through the FSA
portal at www.benefitsolver.com.
2. You can fill out a claim form and submit it along with
your receipts via fax to 855 883 8541 or email at
flexadminstration@businessolver.com
3. You can mail in your claim form and receipts.
If you mail your claim, all FSA claim forms should
be sent to:
Section 125 Claims Department
Businessolver, Inc.
PO Box 65948
West Des Moines, IA 50265
If your claim is denied in whole or in part, you will receive
a notice from Businessolver. The notice will explain the
reason for the denial and what additional information or
documentation is required to substantiate the claim.
Online and Mobile Tools
As an FSA participant, you have access to tools and
features that allow you to easily and conveniently
manage your account:
You can use www.benefitsolver.com to:
––
Check your account balance.
––
Check the status of recently submitted claims.
––
Submit new claims for reimbursement.
––
Sign up to have your funds directly deposited into a
bank account.
––
Order new or replacement benefit cards.
Avoiding Balance Forfeitures
There is some risk to contributing to an FSA. If you
do not use the money you contribute during the
calendar year to pay for expenses, you must forfeit
what is left over.
When Coverage Ends
Your participation in the Flexible Spending Account ends
when any of the following occurs:
––
Your employment with the company ends.
––
You retire.
––
You die.
––
You experience a Qualified Life Event that results in
your decision to end your participation.
Keep in mind that claims may be submitted for
reimbursement for expenses incurred before the date
your participation in the plan ended. Any funds left in the
account at the end of the calendar year and after all
eligible claims have been submitted for reimbursement
are forfeited.
21

2016 DLL Benefits Guide
22

Dental Insurance Coverage
DLL offers a comprehensive dental plan administered by
United Concordia (UCCI). Overall, UCCI has a dental
network that enables you to access the greatest value for
services provided in your geographic area. Under this
plan, you do not need to choose a primary care dentist;
you have the flexibility of choosing any licensed dentist to
provide your dental services, and you can enhance the
amount of your benefits by utilizing a network provider.
Coverage is based on the plan’s maximum allowable
charge (MAC). Network providers agree to accept UCCI’s
MAC for covered services as payment in full and also
agree to file claims for you.
If you or your family members receive services from
a non-network provider, UCCI will apply the percentages
shown in the table below to the non-network
reimbursement for covered services, and you will be
responsible for the difference up to the provider’s
charge. United Concordia’s standard exclusions
and limitations apply.
The table below illustrates covered expenses and
program maximums/deductible. Keep in mind that for
services obtained outside of the UCCI network, our
company has negotiated for reasonable and customary
charges at the 90th percentile for all geographic areas
where services are provided to you.
Important Note:
Benefits include full mouth composite (white)
fillings and Adult Orthodontia.
Benefit Category
Plan Pays
Class I - Diagnostic/Preventive Services Network Advantage Plus PPO Non-Network
Exams
Cleanings & Fluoride Treatments
X-rays
Space Maintainers
100% 100%
Class II – Basic Services
Palliative Treatment (Emergency)
Basic Restorative (Includes Posterior
Composite Fillings)
Simple Extractions
Endodontics
Nonsurgical Periodontics
Surgical Periodontics
Oral Surgery
General Anesthesia
Class III – Major Services
Inlays, Onlays, Crowns
Prosthetics (Bridges, Dentures)
Repair of Dentures
80% 80%
60% 60%
Orthodontics
Diagnostic, Active, Retention Treatment 50% 50%
Included Plan Features
Smile for Health®--Wellness3 Provides
periodontal care for people with certain chronic medical
conditions: diabetes, heart disease, lupus, oral cancer,
organ transplant, rheumatoid arthritis and stroke
• Covers 1 additional periodontal maintenance per year at 100%
• Scaling and root planing are covered at 100%
• 4 periodontal surgery procedures are covered at 100%
Program Maximums/Deductibles
Annual Program Maximum (per covered person) $3,000
Lifetime Orthodontic Maximum (per covered person) $1,000
Annual Program Deductible*
$50 Single/$150 Family
*Annual Deductible excludes Class I Services and Orthodontics.
Class 1: Diagnostic/Preventive services do not count towards your annual maximum.
23

2016 DLL Benefits Guide
Vision Plan Highlights
DLL provides a comprehensive vision benefit
through the EyeMed program for you and your
eligible family members. EyeMed’s vision benefit is
designed to provide routine preventive care such as
eye exams, eyewear and other vision services along
with discounts on a second pair of glasses and balances
over your allowances.
EyeMed has a large network of providers that offers a
wide selection of eyewear for you to choose from. You’ll
receive the most out of your benefit when you visit an
EyeMed eye doctor, including discounts on non-covered
services and selections.
The EyeMed network is comprised of both independent
and optical retail locations. You’ll have access to
thousands of private practitioners and the nation’s
leading optical retailers: LensCrafters, Target Optical,
JCPenney Optical, Sears Optical and most Pearle
Vision locations.
Because many eye and vision conditions exhibit no obvious symptoms,
individuals are often unaware that there is a problem. Early diagnosis and
treatment of eye disorders such as cataracts, glaucoma and macular
degeneration are important for maintaining good vision and preventing
permanent vision loss.
Adults should have at least one eye exam between the ages of 20 and 29,
two exams between ages 30 and 39, one exam every four years from age
40 to 65 and one exam every one or two years after age 65.
Here’s how to get started
To access your vision benefit:
1. For a complete list of providers near you, use the Provider Locator
on www.eyemed.com and choose the INSIGHT network or call
1-866-804-0982.
2. Schedule an appointment. When making the appointment, tell the
office that you are an EyeMed member and provide your name, the
name of your organization or plan, and your member ID number.
3. When you arrive, identify yourself as an EyeMed member and present
your ID card.
4. Your EyeMed provider will take care of the rest!
Need eye exams or eyewear?
1-866-804-0982 (EyeMed)
Monday—Saturday 8am to 11pm
Sundays 11am to 8pm Eastern Time
Ready for LASIK?
For Lasik providers, call 877 5LASER6 or visit www.eyemedlasik.com
To learn more about EyeMed
Visit www.eyemed.com
To locate a participating provider, visit the EyeMed
website at www.eyemed.com and choose the
INSIGHT network.
EyeMed Vision
Feature/Service In-Network Out-of-Network
Frequency of Exams, Lenses,
Contacts, & Frames
Exams, Lenses, Contacts: Once every 12 months
Frames: Once every 24 months
Exam Copay $0 Copay Up to $30 reimbursement
Basic Lenses Copay
Single Vision $20 Copay Up to $25 reimbursement
Lined Bifocal $20 Copay Up to $40 reimbursement
Lined Trifocal $20 Copay Up to $60 reimbursement
Lenticular $20 Copay Up to $80 reimbursement
Frames
Frame Allowance
Contact Lens (instead of glasses)
$0 Copay, up to $150 retail allowance,
then 20% discount off balance
Up to $75 reimbursement
Elective Conventional Up to $150 allowance Up to $120 reimbursement
Medically Necessary Paid in Full Up to $210 reimbursement
24

Additional Benefits
401(k) Retirement Savings Plan
DLL values its members and encourages their
enrollment in the company-sponsored 401(k)
Retirement Savings Plan. Members can contribute up to
100% of their earnings up to the IRS annual maximum
on a tax-deferred basis. DLL will match 100% of the first
4% of your compensation. The company match begins
immediately upon participation. Members over age 50
can also contribute a catch-up contribution up to the
IRS annual maximum. You are 100% vested in both your
money and the company match.
Employee Assistance Program (EAP)
The Employee Assistance Program (EAP) provides
professional confidential counseling service to you
and your eligible dependents to help you and your
family work through issues before they become
unmanageable. No enrollment is necessary.
Reminder: EAP — The EAP provides
professional counseling in a confidential
setting to help you and your family
work through issues before they
become unmanageable.
DLL provides this benefit because we care about our
members, and we encourage you and your family to use
the EAP services whenever you need help or information
to handle your work or family responsibilities.
The EAP can provide assistance with family/marital
counseling, depression/anxiety, alcohol/substance
abuse, legal/financial resources, child/elder care, and
work related issues.
529 College Savings Plan
A TAP 529 College Saving Plan is a tax-smart way to
save now for future education costs. DLL makes it easy
– you can set up payroll deductions. Visit or
contact your bank to open a TAP 529 account.
Education Assistance
DLL recognizes that the development of skills and
knowledge are critical to your success and the
continuing success of the company. Members may
receive reimbursement each calendar year for eligible
education expenses, which include tuition and books
for approved programs.
Hyatt Pre-Paid Legal
The prepaid legal plan includes office and telephone
consultations with lawyers, defense of civil lawsuits, and
will and estate planning. Members are responsible for
paying the premium for this benefit and should contact
Businessolver to enroll.
Veterinary Pet Insurance (VPI)
You have your choice of two plans that help to pay for
veterinary lab fees, treatments, prescriptions, surgery
and more. For more information and to enroll in this
benefit, please contact VPI directly.
25

2016 DLL Benefits Guide
Employee Costs (biweekly)
Medical/Prescription Coverage
HDHP/HSA Plan EPO Plan PPO Plan
Employee $41.30 $55.12 $70.02
Employee & Child(ren) $69.79 $82.48 $110.75
Employee & Spouse/
Domestic Partner
$73.38 $87.58 $117.38
Family $105.68 $133.49 $177.04
Dental/Vision Coverage
Dental Plan
Vision
Employee $10.20 Employee $1.30
Employee & Child(ren) $29.35 Employee & Child(ren) $3.32
Employee & Spouse/
Domestic Partner
$29.35 Employee & Spouse/
Domestic Partner
$3.32
Family $29.35 Family $3.32
Businessolver or DLLbenefits.com
can provide you with additional cost
information for:
— Supplemental Life and AD&D Insurance
If you have any questions, visit
DLLbenefits.com or contact
Businessolver at 855 851 6801.
26

Required Annual Employer
Health Plan Notification
Availabilty of Summary Health Information
As an employee, the health benefits available to you
represent a significant component of your
compensation package. They also provide important
protection for you and your family in the case of illness
or injury.
Your plan offers a series of health coverage options.
Choosing a health coverage option is an important
decision. To help you make an informed choice, your
plan makes available a Summary of Benefits and
Coverage (SBC), which summarizes important
information about any health coverage option in a
standard format, to help you compare across options.
The SBC is available on the web at: DLLbenefits.com.
A paper copy is also available, free of charge, by calling
855 851 6801 (a toll-free number).
HIPAA Special Enrollment Rights
A federal law called HIPAA requires that we notify you about
an important provision in the plan - your right to enroll in the
plan under its “special enrollment provision” if you acquire a
new dependent, or if you decline coverage under this plan
for yourself or an eligible dependent while other coverage is
in effect and later lose that other coverage for certain
qualifying reasons.
––
Loss of Other Coverage (Excluding Medicaid or a State
Children’s Health Insurance Program). If you decline
enrollment for yourself or for an eligible dependent
(including your spouse) while other health insurance or
group health plan coverage is in effect, you may be able to
enroll yourself and your dependents in this plan if you or
your dependents lose eligibility for that other coverage
(or if the employer stops contributing toward your or your
dependents’ other coverage). However, you must
request enrollment within 30 days after your or your
dependents’ other coverage ends (or after the employer
stops contributing toward the other coverage).
––
Loss of Coverage for Medicaid or a State Children’s
Health Insurance Program. If you decline enrollment for
yourself or for an eligible dependent (including your
spouse) while Medicaid coverage or coverage under a
state children’s health insurance program is in effect, you
may be able to enroll yourself and your dependents in this
plan if you or your dependents lose eligibility for that
other coverage. However, you must request
enrollment within 60 days after your or your
dependents’ coverage ends under Medicaid or a state
children’s health insurance program.
––
New Dependent by Marriage, Birth, Adoption, or
Placement for Adoption. If you have a new dependent
as a result of marriage, birth, adoption, or placement
for adoption, you may be able to enroll yourself and
your new dependents. However, you must request
enrollment within 30 days after the marriage, birth,
adoption, or placement for adoption.
––
Eligibility for Medicaid or a State Children’s Health
Insurance Program. If you or your dependents
(including your spouse) become eligible for a state
premium assistance subsidy from Medicaid or through
a state children’s health insurance program with
respect to coverage under this plan, you may be able
to enroll yourself and your dependents in this plan.
However, you must request enrollment within 60 days
after your or your dependents’ determination of
eligibility for such assistance.
To request special enrollment or to obtain more information
about the plan’s special enrollment provisions, contact
Businessolver at 855 851 6801.
Women’s Health and Cancer Rights Act
If you have had or are going to have a mastectomy, you may
be entitled to certain benefits under the Women’s Health
and Cancer Rights Act of 1998 (WHCRA). For individuals
receiving mastectomy-related benefits, coverage will be
provided in a manner determined in consultation with the
attending physician and the patient, for:
––
All states of reconstruction of the breast on which the
mastectomy was performed;
––
Surgery and reconstruction of the other breast to
produce a symmetrical appearance;
––
Prostheses; and
––
Treatment of physician complications of the
mastectomy, including lymphedema.
These benefits will be provided subject to the same
deductibles and coinsurance applicable to other medical
and surgical benefits provided under the plan.
If you would like more information on WHCRA benefits,
call Businessolver at 855 851 6801 for more information.

27

2016 DLL Benefits Guide
Premium Assistance Under
Medicaid and the Children’s
Health Insurance Program
(CHIP)
If you or your children are eligible for Medicaid or CHIP
and you’re eligible for health coverage from your
employer, your state may have a premium assistance
program that can help pay for coverage, using funds
from their Medicaid or CHIP programs. If you or your
children aren’t eligible for Medicaid or CHIP, you won’t be
eligible for these premium assistance programs but you
may be able to buy individual insurance coverage
through the Health Insurance Marketplace. For more
information, visit www.healthcare.gov.
If you or your dependents are already enrolled in
Medicaid or CHIP and you live in a State listed below,
contact your State Medicaid or CHIP office to find out
if premium assistance is available.
If you or your dependents are NOT currently enrolled
in Medicaid or CHIP, and you think you or any of your
dependents might be eligible for either of these
programs, contact your State Medicaid or CHIP office or
dial 877 KIDS NOW or www.insurekidsnow.gov to find
out how to apply. If you qualify, ask your state if it has a
program that might help you pay the premiums for an
employer-sponsored plan.
If you or your dependents are eligible for premium
assistance under Medicaid or CHIP, as well as eligible
under your employer plan, your employer must allow
you to enroll in your employer plan if you aren’t already
enrolled. This is called a “special enrollment” opportunity,
and you must request coverage within 60 days of
being determined eligible for premium assistance.
If you have questions about enrolling in your employer
plan, contact the Department of Labor at
www.askebsa.dol.gov or call 866 444 EBSA (3272).
If you live in one of the following States, you may be
eligible for assistance paying your employer health plan
premiums. The following list of States is current as of
July 31, 2015. You should contact your State for further
information on eligibility:
ALABAMA – Medicaid
Website: www.myalhipp.com/
Phone: 855 692 5447
ALASKA – Medicaid
Website: www.myakhipp.com/
Phone (Outside of Anchorage): 888.318.8890
Phone (Anchorage): 907 269 6529
COLORADO – Medicaid
Medicaid Website: www.mycohibi.com/
Medicaid Customer Contact Center: 800 221 3943
FLORIDA – Medicaid
Website: www.flmedicaidtplrecovery.com/
Phone: 877 357 3268
GEORGIA – Medicaid
Website: dch.georgia.gov/
Click on Programs, then Medicaid, then Health Insurance Premium
Payment (HIPP)
Phone: 404 656 4507
INDIANA – Medicaid
Website: www.in.gov/fssa
Phone: 800 889 9949
IOWA – Medicaid
Website: www.dhs.state.ia.us/hipp/
Phone: 888 346 9562
KANSAS – Medicaid
Website: www.kdheks.gov/hcf/
Phone: 800 792 4884
KENTUCKY – Medicaid
Website: chfs.ky.gov/dms/default.htm
Phone: 800 635 2570
LOUISIANA – Medicaid
Website: www.lahipp.dhh.louisiana.gov
Phone: 888 695 2447
MAINE – Medicaid
Website: www.maine.gov/dhhs/ofi/public-assistance/index.html
Phone: 800 977 6740
TTY 800 977 6741
MASSACHUSETTS – Medicaid and CHIP
Website: www.mass.gov/MassHealth
Phone: 800 462 1120
MINNESOTA – Medicaid
Website: www.dhs.state.mn.us/
Click on Health Care, then Medical Assistance
Phone: 800 657 3629
MISSOURI – Medicaid
Website: www.dss.mo.gov/mhd/participants/pages/hipp.htm
Phone: 573 751 2005
MONTANA – Medicaid
Website: http://medicaid.mt.gov/member
Phone: 800 694 3084
NEBRASKA – Medicaid
Website: www.ACCESSNebraska.ne.gov
Phone: 855 632 7633
NEVADA – Medicaid
Medicaid Website: dwss.nv.gov/ Medicaid
Phone: 800 992 0900
28

NEW HAMPSHIRE – Medicaid
Website: www.dhhs.nh.gov/oii/documents/hippapp.pdf
Phone: 603 271 5218
NEW JERSEY – Medicaid and CHIP
Medicaid Website: www.state.nj.us/humanservices/dmahs/ clients/
medicaid/
Medicaid Phone: 609 631 2392
CHIP Website: www.njfamilycare.org/index.html
CHIP Phone: 800 701 0710
NEW YORK – Medicaid
Website: www.nyhealth.gov/health_care/medicaid/
Phone: 800 541 2831
NORTH CAROLINA – Medicaid
Website: www.ncdhhs.gov/dma
Phone: 919 855 4100
NORTH DAKOTA – Medicaid
Website: www.nd.gov/dhs/services/medicalserv/medicaid/
Phone: 800 755 2604
OKLAHOMA – Medicaid and CHIP
Website: www.insureoklahoma.org
Phone: 888 365 3742
OREGON – Medicaid
Website: www.oregonhealthykids.gov
www.hijossaludablesoregon.gov
Phone: 800 699 9075
PENNSYLVANIA – Medicaid
Website: www.dpw.state.pa.us/hipp
Phone: 800 692 7462
RHODE ISLAND – Medicaid
Website: www.ohhs.ri.gov
Phone: 401 462 5300
SOUTH CAROLINA – Medicaid
Website: www.scdhhs.gov
Phone: 888 549 0820
SOUTH DAKOTA – Medicaid
Website: dss.sd.gov
Phone: 888 828 0059
TEXAS – Medicaid
Website: www.gethipptexas.com/
Phone: 800 440 0493
UTAH – Medicaid and CHIP
Website: health.utah.gov/upp
Phone: 866 435 7414
VERMONT – Medicaid
Website: www.greenmountaincare.org/
Phone: 800 250 8427
VIRGINIA – Medicaid and CHIP
Medicaid Website: www.coverva.org/programs_premium_assistance.cfm
Phone: 800 432 5924
CHIP Website: www.coverva.org/programs_premium_assistance.cfm
CHIP Phone: 855 242 8282
WASHINGTON – Medicaid
Website: www.hca.wa.gov/medicaid/premiumpymt/pages/index.aspx
Phone: 800 562 3022 ext. 15473
WEST VIRGINIA – Medicaid
Website: www.dhhr.wv.gov/bms/
Phone: 877 598 5820, HMS Third-Party Liability
WISCONSIN – Medicaid
Website: www.badgercareplus.org/pubs/p-10095.htm
Phone: 800 362 3002
WYOMING – Medicaid
Website: health.wyo.gov/healthcarefin/equalitycare
Phone: 307 777 7531
To see if any more States have added a premium
assistance program since July 31, 2014, or for more
information on special enrollment rights, you can
contact either:
U.S. Department of Labor
Employee Benefits Security Administration
www.dol.gov/ebsa
866 444 EBSA (3272)
U.S. Department of Health and Human Services
Centers for Medicare & Medicaid Services
www.cms.hhs.gov
877 267 2323, Menu Option 4, Ext. 61565
29

2016 DLL Benefits Guide
References and Resources
Have a question about one of your benefits?
Keep this brochure handy for a quick reference
for all your benefit needs.
Plan Administrator Website Phone Number
Enrollment, Questions, Life Events Businesssolver DLLbenefits.com 855 851 6801
Medical Benefits Blue Cross mybenefitshome.com 866 727 4942
Prescription Benefits FutureScripts 855 390 2604
Nurse Line/Health Coaching Blues on Call 888 258 3428
Dental Benefits United Concordia unitedconcordia.com 800 332 0366
Vision Benefits Eyemed www.eyemed.com 866 804 0982
Disability & FMLA Unum www.unum.com 866 779 1054
Flexible Spending Accounts Businessolver DLLbenefits.com 855 883 8541
Employee Assistance Plan HMS hmsincorp.com
Username: DLL
800 343 2186
401(k) Retirement Savings Plan The Vanguard Group vanguard.com 800 523 1188
Pre-Paid Legal Hyatt legalplans.com
800 821 6400
Password: 570005
Pet Insurance Veterinary Pet Insurance (VPI) petinsurance.com/eb 800 872 7387
Accident Insurance MetLife metlife.com 800 GET MET8
Critical Illness MetLife metlife.com 800 GET MET8
30

HR One Call
x5555
1 866 258 4762
Option 1: Benefits*
Option 2: Payroll & eTime
Option 3: Recruitment
Option 4: Training
*Benefits Menu
1: Benefits Services Center
2: Vanguard (401k)
3: IBC (Medical)
4: Future Scripts (Rx)
5: United Concordia (Dental)
6: EyeMed (Vision)
7: Unum (Disability & FMLA)
8: Hear more DLL Benefits:
• Employee Assistance
Program (EAP)
• HomeEssentials
Contractor Network
• Hyatt Legal
• MetLife Home & Auto
Insurance
• Pet Insurance
• Accident Insurance
• Critical Illness
Option 5: Verification
of Employment
Option 6: Other Inquiries
31

De Lage Landen Financial Services, Inc.
1111 Old Eagle School Road
Wayne, PA 19087
www.dllgroup.com